Imaging Anatomy Brain and Spine Osborn 1 Ed 2020 PDF

IMAGING ANATOMY: Brain and
Spine
Anne G. Osborn, MD, FACR

University Distinguished Professor and Professor of Radiology and
Imaging Sciences, William H. and Patricia W. Child Presidential
Endowed, Chair in Radiology, University of Utah School of Medicine,
Salt Lake City, Utah
Karen L. Salzman, MD
Professor of Radiology and Imaging Sciences, Neuroradiology Section
Chief and Fellowship Director, Leslie W. Davis Endowed Chair in
Neuroradiology, University of Utah School of Medicine, Salt Lake City,
Utah
Jeffrey S. Anderson, MD, PhD

Professor of Radiology and Imaging Sciences, Director of Functional
Neuroimaging, Principal Investigator, Brain Network Laboratory,
University of Utah School of Medicine, Salt Lake City, Utah
Arthur W. Toga, PhD

Professor, Departments of Ophthalmology, Neurology, Psychiatry and
Behavior Sciences, Radiology, and Biomedical Engineering, Director of
USC Mark and Mary Stevens Neuroimaging and Informatics Institute,
Director of USC Laboratory of Neuroimaging, Keck School of Medicine
of USC, University of Southern California, Los Angeles, California
Meng Law, MD, MBBS, FRANZCR
Professor, Departments of Neurological Surgery and Biomedical
Engineering, USC Mark and Mary Stevens Neuroimaging and
Informatics Institute, Keck School of Medicine of USC, Viterbi School of
Engineering of USC, University of Southern California, Los Angeles,
California
Director of Radiology and Nuclear Medicine, Alfred Health, Professor
and Chair of Radiology, Monash Electrical and Computer Systems
Engineering, Department of Neuroscience, Monash School of Medicine,
Nursing and Health Sciences, Monash University, Melbourne,
Australia
Jeffrey S. Ross, MD
Consultant, Neuroradiology Division, Department of Radiology, Mayo
Clinic in Arizona
Professor of Radiology, Mayo Clinic College of Medicine, Phoenix,
Arizona
Kevin R. Moore, MD
Pediatric Radiologist and Neuroradiologist, Primary Children’s
Hospital, Salt Lake City, Utah
Table of Contents
Cover image
Title page
Copyright
Dedications
Contributing Authors
Preface
Acknowledgments
Sections
Part I: Brain
SECTION 1: SCALP, SKULL, AND MENINGES

Chapter 1: Scalp and Calvarial Vault
Chapter 2: Cranial Meninges
Chapter 3: Pia and Perivascular Spaces
SECTION 2: SUPRATENTORIAL BRAIN

ANATOMY
Chapter 4: Cerebral Hemispheres Overview
Chapter 5: Gyral/Sulcal Anatomy
Chapter 6: White Matter Tracts
Chapter 7: Basal Ganglia and Thalamus
Chapter 8: Other Deep Gray Nuclei
Chapter 9: Limbic System
Chapter 10: Sella, Pituitary, and Cavernous Sinus
Chapter 11: Pineal Region

Chapter 12: Primary Somatosensory Cortex (Areas 1, 2, 3)
Chapter 13: Primary Motor Cortex (Area 4)
Chapter 14: Superior Parietal Cortex (Areas 5, 7)
Chapter 15: Premotor Cortex and Supplementary Motor Area

(Area 6)
Chapter 16: Superior Prefrontal Cortex (Area 8)
Chapter 17: Dorsolateral Prefrontal Cortex (Areas 9, 46)
Chapter 18: Frontal Pole (Area 10)
Chapter 19: Orbitofrontal Cortex (Area 11)
Chapter 20: Insula and Parainsula Areas (Areas 13, 43)
Chapter 21: Primary Visual and Visual Association Cortex (Areas

17, 18, 19)
Chapter 22: Temporal Cortex (Areas 20, 21, 22)
Chapter 23: Posterior Cingulate Cortex (Areas 23, 31)

Chapter 24: Anterior Cingulate Cortex (Areas 24, 32, 33)
Chapter 25: Subgenual Cingulate Cortex (Area 25)
Chapter 26: Retrosplenial Cingulate Cortex (Areas 29, 30)
Chapter 27: Parahippocampal Gyrus (Areas 28, 34, 35, 36)
Chapter 28: Fusiform Gyrus (Area 37)
Chapter 29: Temporal Pole (Area 38)
Chapter 30: Inferior Parietal Lobule (Areas 39, 40)
Chapter 31: Primary Auditory and Auditory Association Cortex

(Areas 41, 42)
Chapter 32: Inferior Frontal Gyrus (Areas 44, 45, 47)
SECTION 3: BRAIN NETWORK ANATOMY
Chapter 33: Functional Network Overview
Chapter 34: Neurotransmitter Systems

Chapter 35: Default Mode Network
Chapter 36: Attention Control Network
Chapter 37: Sensorimotor Network
Chapter 38: Visual Network
Chapter 39: Limbic Network
Chapter 40: Language Network
Chapter 41: Memory Network
Chapter 42: Social Network
SECTION 4: INFRATENTORIAL BRAIN
Chapter 43: Brainstem and Cerebellum Overview
Chapter 44: Midbrain
Chapter 45: Pons
Chapter 46: Medulla

Chapter 47: Cerebellum
Chapter 48: Cerebellopontine Angle/IAC
SECTION 5: CSF SPACES
Chapter 49: Ventricles and Choroid Plexus
Chapter 50: Subarachnoid Spaces/Cisterns
SECTION 6: SKULL BASE AND CRANIAL NERVES
Chapter 51: Skull Base Overview
Chapter 52: Anterior Skull Base
Chapter 53: Central Skull Base
Chapter 54: Posterior Skull Base
Chapter 55: Cranial Nerves Overview
Chapter 56: Olfactory Nerve (CNI)

Chapter 57: Optic Nerve (CNII)
Chapter 58: Oculomotor Nerve (CNIII)
Chapter 59: Trochlear Nerve (CNIV)
Chapter 60: Trigeminal Nerve (CNV)
Chapter 61: Abducens Nerve (CNVI)
Chapter 62: Facial Nerve (CNVII)
Chapter 63: Vestibulocochlear Nerve (CNVIII)
Chapter 64: Glossopharyngeal Nerve (CNIX)
Chapter 65: Vagus Nerve (CNX)
Chapter 66: Accessory Nerve (CNXI)
Chapter 67: Hypoglossal Nerve (CNXII)
SECTION 7: EXTRACRANIAL ARTERIES
Chapter 68: Aortic Arch and Great Vessels

Chapter 69: Cervical Carotid Arteries
SECTION 8: INTRACRANIAL ARTERIES
Chapter 70: Intracranial Arteries Overview
Chapter 71: Intracranial Internal Carotid Artery
Chapter 72: Circle of Willis
Chapter 73: Anterior Cerebral Artery
Chapter 74: Middle Cerebral Artery
Chapter 75: Posterior Cerebral Artery
Chapter 76: Vertebrobasilar System
SECTION 9: VEINS AND VENOUS SINUSES
Chapter 77: Intracranial Venous System Overview
Chapter 78: Dural Sinuses

Chapter 79: Superficial Cerebral Veins
Chapter 80: Deep Cerebral Veins
Chapter 81: Posterior Fossa Veins
Chapter 82: Extracranial Veins
Part II: Spine
SECTION 1: VERTEBRAL COLUMN, DISCS, AND

PARASPINAL MUSCLE
Chapter 83: Vertebral Column Overview
Chapter 84: Ossification
Chapter 85: Vertebral Body and Ligaments
Chapter 86: Intervertebral Disc and Facet Joints
Chapter 87: Paraspinal Muscles
Chapter 88: Craniocervical Junction

Chapter 89: Cervical Spine
Chapter 90: Thoracic Spine
Chapter 91: Lumbar Spine
Chapter 92: Sacrum and Coccyx
SECTION 2: CORD, MENINGES, AND SPACES
Chapter 93: Spinal Cord and Cauda Equina
Chapter 94: Meninges and Compartments
SECTION 3: VASCULAR
Chapter 95: Spinal Arterial Supply
Chapter 96: Spinal Veins and Venous Plexus
SECTION 4: PLEXI AND PERIPHERAL NERVES
Chapter 97: Brachial Plexus

Chapter 98: Lumbar Plexus
Chapter 99: Sacral Plexus and Sciatic Nerve
Chapter 100: Peripheral Nerve and Plexus Overview
INDEX
Copyright
Elsevier
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IMAGING ANATOMY: BRAIN AND SPINE
ISBN: 978-0-323-66114-0
Inkling: 9780323661157
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Library of Congress Control Number: 2020932662
Cover Designer: Tom M. Olson, BA

Printed in Canada by Friesens, Altona, Manitoba, Canada
Last digit is the print number: 9 8 7 6

5 4 3 2 1
Dedications
For Lucy
AGO
For the lights of my life: Sophia, Aubrey, and Ian
KLS
For Emma
JSA
For family, always
AWT
For Mom and Dad, Sue and Lawrence
ML
For Peggy
JSR
For Margaret, Hannah, Andrew, and Carlie
KRM
Contributing Authors
Giuseppe Barisano, MD, Research Scientist, Laboratory of Neuro
Imaging, USC Mark and Mary Stevens Neuroimaging and Informatics
Institute, Keck School of Medicine of USC, University of Southern
California, Los Angeles, California
Ryan P. Cabeen, PhD, Postdoctoral Scholar, Laboratory of Neuro
Imaging, USC Mark and Mary Stevens Neuroimaging and Informatics
Institute, Keck School of Medicine of USC, University of Southern
California, Los Angeles, California
Adriene C. Eastaway, MD, MS, University of Utah School of
Medicine, Salt Lake City, Utah
Edward P. Quigley, III, MD, PhD, Associate Professor, Radiology
and Imaging Sciences, Adjunct Associate Professor Neurology,
University of Utah Medical Center, Salt Lake City, Utah
Farshid Sepehrband, PhD, MS, BS, Assistant Professor, Laboratory
of Neuro Imaging, USC Mark and Mary Stevens Neuroimaging and
Informatics Institute, Keck School of Medicine of USC, University of
Southern California, Los Angeles, California
Additional Contributing Authors

Philip R. Chapman, MD
Siddhartha Gaddamanugu, MD
Bronwyn E. Hamilton, MD
H. Ric Harnsberger, MD
Jared A. Nielsen, PhD
Lubdha M. Shah, MD
Aparna Singhal, MD
Surjith Vattoth, MD, FRCR
Preface
Anatomy and pathology are the foundational elements of
neuroradiology. When we first conceived the Diagnostic Imaging
and the Imaging A natomy series, Ric Harnsberger and I knew that
they would need to evolve as our understanding of brain function,
connectivity, and gross anatomy grew and our imaging became
progressively more sophisticated. While brain anatomy doesn’t
change, our imaging of it does. A decade ago, 3T MR was cu ing-
edge. Now it’s standard, and field strengths of 7T and beyond are
the new frontiers.
This new edition of Imaging A natomy: Brain and Spine (Head and
Neck has been split off as its own volume) gives you more of the
gorgeous color graphics you’ve come to expect of us, combined
with standard 1.5 and 3T MR and DS A. This new volume also
includes state-of-the-art 7T imaging, tractography, and the
fundamentals of fMRI (anatomy, function, and connectivity) for
your delectation and delight. Ever-increasingly sophisticated
graphics and expanded imaging display techniques can now be
employed to depict the brain vasculature. S ome of these visually
stunning images are illustrated in this text, courtesy of Drs. Edward
Quigley, Michael Bayona, and Adriene Eastaway.
The ultra-high field 7T MR images are courtesy of Drs. Farshid
S epehrband, Ryan Cabeen, G iuseppe Barisano, and Ms. K atherin
Martin.
The spine section has been expanded and updated by Drs. J eff
Ross and K evin Moore. It now includes both adult and pediatric
anatomy and extensive coverage of the axial skeleton and the
lumbar and brachial plexuses (CT, MR, DSA, and ultrasound).
We hope that this new volume will augment your understanding
and increase your appreciation for—and understanding of—the
neuroanatomy and function we see depicted every day in our
practices.
Anne G. Osborn, MD, FACR, University Distinguished Professor and Professor
of Radiology and Imaging Sciences, William H. and Patricia W. Child Presidential Endowed Chair in
Radiology, University of Utah School of Medicine, Salt Lake City, Utah
Acknowledgments
LEAD EDITOR
Rebecca L. Bluth, BA
TEXT EDITORS
Arthur G. Gelsinger, MA
Nina I. Themann, BA
Terry W. Ferrell, MS
Megg Morin, BA
Kathryn Watkins, BA
IMAGE EDITORS
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS
ILLUSTRATIONS
Richard Coombs, MS
Lane R. Bennion, MS
Laura C. Wissler, MA
ART DIRECTION AND DESIGN

Tom M. Olson, BA
PRODUCTION EDITORS
Emily C. Fassett, BA
John Pecorelli, BS
Sections
PART I Brain
SECTION 1: Scalp, Skull, and Meninges
SECTION 2: Supratentorial Brain Anatomy
SECTION 3: Brain Network Anatomy
SECTION 4: Infratentorial Brain
SECTION 5: CSF Spaces
SECTION 6: Skull Base and Cranial Nerves
SECTION 7: Extracranial Arteries
SECTION 8: Intracranial Arteries
SECTION 9: Veins and Venous Sinuses
PART II Spine
SECTION 1: Vertebral Column, Discs, and Paraspinal Muscle
SECTION 2: Cord, Meninges, and Spaces
SECTION 3: Vascular
SECTION 4: Plexi and Peripheral Nerves
PA R T I
Brain
Outline

Chapter 15: Premotor Cortex and Supplementary Motor
Area (Area 6)
Chapter 21: Primary Visual and Visual Association Cortex
(Areas 17, 18, 19)
Chapter 27: Parahippocampal Gyrus (Areas 28, 34, 35,
36)
Chapter 31: Primary Auditory and Auditory Association
Cortex (Areas 41, 42)
Chapter 45: Pons
Chapter 46: Medulla
SECT ION 1
SCALP, SKULL, AND MENINGES
Outline

Scalp and Calvarial Vault
Main Text
T ERM INOLOGY
Definitions
• Bregma
Meeting of sagittal, coronal sutures (anterior fontanelle
in neonates)
• Lambda
Meeting of sagittal, lambdoid sutures (site of posterior
fontanelle in neonates)
• Pterion
H-shaped junction
– Between frontal, parietal bones plus greater
sphenoid wing, squamous temporal bone
Site of anterolateral, i.e., sphenoidal, fontanelle
GROSS ANATOMY
Overview
• Scalp
Scalp has 5 layers
– Skin
Epidermis, dermis, hair, sebaceous glands
– Subcutaneous tissue
Very vascular fibroadipose tissue
– Epicranial tissue
Scalp muscles, galea aponeurotica
– Subaponeurotic tissue
Loose areolar connective tissue
– Pericraniu m
Periosteum of skull
Continues through sutures to outer layer of dura
• Skull (28 separate bones, mostly connected by fibrous
sutures)
Cranium has several parts
– Calvarial vault
– Cranial base
– Facial skeleton
Calvarial vault composed of several bones
– Frontal bone
– Paired parietal bones
– Squamous occipital bone
– Paired squamous temporal bones
3 major serrated fibrous joints ( sutures ) connect bones
of vault
– Coronal suture
– Sagittal suture
– Lambdoid suture
Outer, inner tables
– 2 thin plates of compact cortical bone
– Separated by diploic space (cancellous bone
containing marrow)
Endocranial surface
– Lined by outer (periosteal) layer of dura
– Grooved by vascular furrows
– May have areas of focal thinning (arachnoid
granulations), foramina (emissary veins)
IMAGING ANATOMY
Overview
• Scalp largely high signal (fat) on T1WI

• Calvarium low-signal outer/inner tables; diploic space filled
with fatty marrow, usually high signal on T1WI
Frontal bones
– Frontal sinuses show wide variation in aeration
– Frontal bones often appear thickened, hyperostotic
(especially in older females)
Parietal bones
– Areas of parietal thinning, granular foveolae (for
arachnoid granulations) common adjacent to
sagittal suture
– Inner tables often slightly irregular (convolutional
markings caused by gyri), grooved by paired middle
meningeal arteries + vein
Occipital bone
– Deeply grooved by superior sagittal, transverse
sinuses
– Internal occipital protuberance marks sinus
confluence (torcular Herophili)
Temporal bones
– Thin, inner surface grooved by middle meningeal
vessels
– Outer surface grooved by superficial temporal artery
ANATOMY IMAGING ISSUES

Imaging Recommendations
• Use bone algorithm

Not just soft tissue algorithm with bone windows!
Should be routine on all head CT scans
• 3D volume-rendered NECT excellent for overall calvarial
anatomy, suspected craniosynostosis
• Contrast-enhanced fat-suppressed MR excellent for
suspected calvarial, dural lesions
Imaging Pitfalls
• Most common cause of "thick skull" is normal variant

• Striking hyperostosis, especially of frontal bone, common in
older females
• Areas of calvarial thinning, lucencies (foramina, vascular
grooves, diploic venous lakes) are normal (should not be
mistaken for osteolytic metastases)
• Vascular grooves are corticated, usually less distinct than
acute linear skull fracture
EMBRYOLOGY
Embryologic Events
• Skull base formed from enchondral ossification

• Calvarial vault forms via membranous ossification
Curved mesenchymal plates appear at day 30
Extend toward each other, skull base
As paired bones meet in midline, metopic and sagittal
sutures are induced
– Coronal suture is present from onset of ossification
Unossified centers at edges of parietal bone form
fontanelles
Vault grows rapidly in 1st postnatal year
– If separate ossification center develops, "sutural"
("wormian") bone forms
Image Gallery
Print Images
GRAPHICS
Graphic depiction of cranium, frontal view, is shown. Frontal

bone is rendered in purple. Two parts of the sphenoid bone
are shown here: The greater and lesser wings, separated
by the superior orbital fissure (SOF). The optic canal lies
just above the SOF and is separated from it by a bony optic
strut.
Lateral view of the calvarial vault is shown. The pterion is a
small area on the lateral skull at the intersection of the
frontal, sphenoid, parietal, and temporal squama. It is an
important landmark for surgical approach to the sylvian
fissure and middle cranial fossa.
Scalp and calvarium are depicted in cross section. The 5
scalp layers are depicted. Skin consists of epidermis and
dermis. Hair follicles and a sebaceous gland, the
subcutaneous fibroadipose tissue, sweat glands and ducts,
as well as superficial and deep cutaneous vascular plexi are
shown.
AXIAL NECT
Five sequential axial NECT images presented from inferior
to superior through skull base, calvarium, are depicted.
Section through skull base shows major bones, sutures
forming skull base. Sphenosquamosal, petrooccipital,
occipitomastoid sutures are normally well seen and should
not be confused with fractures.
Section through upper skull base shows anterior, middle,
and posterior cranial fossae as well as formation of lower
vault by frontal, greater wing sphenoid, squamous temporal,
and occipital bones.
Section through lower calvarial vault showing
anteroposterior linear configuration of squamosal suture, not
to be confused with a fracture. Major bones forming vault
are frontal, parietal, and occipital bones, which are now all
visible.
AXIAL NECT AND 3T SAGITTAL T1 MR

Section through vault shows the frontal, parietal, and
occipital bones separated by coronal and lambdoid sutures.
The calvarium consists of compact bone forming the
external and inner tables with interposed diploic space.
Section through upper vault shows coronal, sagittal, and
lambdoid sutures separating frontal, parietal, and occipital
bones. The junction between the coronal and sagittal
sutures is the bregma. Sagittal and lambdoid sutures meet
at the lambda.
Sagittal T1 MR volume acquisition with 1-mm sections
shows details of the scalp and calvarial vault. The skin
(epidermis, dermis) and subcutaneous fatty tissue can be
distinguished. Marrow-bearing diploic space is contained
between the hypointense outer/inner tables. The image is of
an 8-year-old child and the hemopoietic marrow is
hypointense. In adults it is hyperintense on T1.
3D-VRT NECT
First of 6 3D reconstruction images using volume rendering
technique (VRT) of data acquired from multislice NECT
shows anterior skull. Anterior calvarial vault is dominated by
frontal bone, which also forms floor of anterior cranial fossa
(roof of orbit).
Anterosuperior view shows coronal suture separating frontal
and parietal bones. Sagittal suture separates paired parietal
bones. Zygomatic arch is formed by zygomatic process of
temporal bone and temporal process of zygomatic bone.
The lateral calvarial vault is formed by parietal bone, with
lesser portions formed by frontal, greater wing sphenoid,
squamous temporal, and occipital bones with intervening
sutures.
Reconstruction of posterior skull formed by posterior
parietal and squamous portion of occipital bones. Parietal
foramina are present, which transmit emissary veins and
may occasionally be particularly large.
View of superior skull shows coronal and sagittal sutures.
Coronal suture separates frontal and parietal bones.
Sagittal suture separates paired parietal bones and extends
from bregma anteriorly to lambda posteriorly.
The inner surface of lateral calvarium shows prominent
groove for middle meningeal artery. Sectioned vault
demonstrates compact external and inner table with
interposed diploic space. Numerous indentations of variable
size called granular foveolae occur in parasagittal parietal
bone into which arachnoid granulations extend.
Cranial Meninges
Main Text
T ERM INOLOGY
Definitions
• "Pachymeninges" (thick meninges): Dura

• Leptomeninges (thin meninges): Arachnoid, pia
• Extradural space (EDS)
Potential space between dura, skull; seen only in
pathologic conditions (infection, hematoma, etc.)
• Subdural space (SDS)
Potential space between inner dura, arachnoid; seen only
in pathologic conditions
• Subarachnoid space (SAS)
Normal cerebrospinal fluid (CSF)-filled space between
arachnoid, pial-covered brain
• Subpial space (SPS)
Potential space between pia, glia limitans of cortex
• Perivascular space (PVS)
Pial-lined, interstitial fluid (ISF)-filled invagination along
penetrating arteries
Key part of brain "glymphatic" system
GROSS ANATOMY
Overview
• Brain encased by 3 meninges

Dura
– Dense fibrocollagenous sheet
– 2 layers: Outer (periosteal) and inner (meningeal)
– Closely adherent except where separate to enclose
venous sinus; also tightly adherent to skull at
sutural attachments
– Outer layer forms periosteum of inner calvarium
– Inner layer folds inward
Forms falx cerebri, tentorium cerebelli, etc.
Continues extracranially (into orbit, through
foramen magnum into spinal canal)
– At other foramina, meningeal dura fuses with
epineurium of cranial/peripheral nerves, adventitia
of carotid/vertebral arteries
– Blood supply from numerous dural vessels, many
with extensive extra/intracranial anastomoses
Middle, accessory meningeal arteries
Cavernous/tentorial branches of internal carotid
artery (ICA)
Posterior meningeal branches of vertebral artery
Transosseous meningeal branches of external
carotid artery (ECA), etc.
– Brain interstitial fluid is collected in perivenous
spaces, enters dural meningeal lymphatics
Dural lymphatics are part of brain's
"glymphatic" system
Provides macroscopic clearance of interstitial
solutes from brain parenchyma
Drainage from dura, paravascular spaces into
cervical lymphatics
Arachnoid
– Thin, nearly transparent
– Outer surface loosely adherent to dura, easily
separated
– Arachnoid follows dura; does not invaginate into
sulci
– SAS lies between arachnoid, pia and is traversed by
sheet-like bridging trabeculae
– Arachnoid villi/granulations = endothelial-lined
extensions of arachnoid + SAS into dural sinus
Pia
– Innermost layer of leptomeninges
– Covers brain, invaginates into sulci
– Follows penetrating cortical arteries into brain,
forming PVSs (Virchow-Robin spaces)
– CSF in PVSs, ISF continuously interchange,
facilitated by AQP4 water channels
IMAGING ANATOMY
Overview
• Dura
Capillaries lack endothelial tight junctions so
macromolecules (e.g., contrast agents) easily leak into
dura
Dura enhances normally on CECT, T1 C+ scans
– Should be smooth, 1-2 mm thick
– Most prominent near vertex, least prominent under
temporal lobes
– Enhancing segments appear discontinuous on 1.5T
but typically well seen on 3T as continuous
curvilinear enhancement that hugs inner calvarium
• Arachnoid
Normally not seen
Pathologic processes typically affect both dura and
arachnoid, which become involved/thickened together
and are indistinguishable on imaging
Arachnoid granulations seen as round/ovoid areas of
CSF density/signal intensity that project into dural
venous sinus (most typically in transverse/sigmoid
sinuses)
Trabeculae/vessels that bridge SAS occasionally seen on
3T T2WI or if they become pathologically enlarged (e.g.,
in Sturge-Weber syndrome)
• Pia normally not seen on imaging but PVSs often normally
seen as linear/ovoid CSF areas in basal ganglia around
anterior commissure, basal ganglia, midbrain, deep cerebral
white matter

• T1 C+ scans in both axial, coronal planes
Imaging Pitfalls
• "Giant" round/ovoid arachnoid granulations (up to 1-2 cm)

May occur as normal variant in dural venous sinuses
Contain CSF, often veins, occasionally small amounts of
brain tissue
Should not be mistaken for thrombus
May not suppress completely on FLAIR
• Veins in, around tentorium may appear quite prominent on
CECT, T1 C+ scans
Should not be mistaken for arteriovenous fistula
Image Gallery
Print Images
GRAPHICS
Oblique sagittal graphic shows the relationship of the major
dural sinuses to the falx cerebri and tentorium cerebelli. The
falx inserts on the crista galli anteriorly and sweeps
backward in the midline to the straight sinus, becoming
taller as it passes posteriorly between the cerebral
hemispheres. The tentorium cerebelli meets the falx cerebri
at the tentorial apex and curves downward to contain the
transverse sinuses. The leaves of the tentorium insert
anteriorly on the petrous apex, and fibers extend forward to
the anterior clinoid processes. The tentorial opening
(incisura) is somewhat U-shaped.
Sagittal graphic depicts cranial leptomeninges enclosing
cerebrospinal fluid (CSF) cisterns (blue). The arachnoid
follows the dura around the inner calvarium and is shown in
purple; the pia (orange) follows the brain surface and dips
into the sulci.
Coronal graphic shows the superior sagittal venous sinus as
it is enclosed between the outer and inner dural layers.
Arachnoid granulations project from the subarachnoid space
into the superior sagittal sinus. Part of the brain's
"glymphatic system," meningeal lymphatics (schematically
depicted in green) drain fluid from the interstitial fluid/CSF
compartment to the deep cervical lymph nodes.
Graphic depicts an arachnoid granulation projecting into a
dural venous sinus. A core of CSF extends from the
subarachnoid space into the granulation and is covered by
an apical cap of arachnoid cells. Channels extend through
the cap to the sinus endothelium and drain CSF into the
venous circulation. Note numerous trabeculae as well as
small arteries and veins within the subarachnoid space over
the brain.
1.5T AXIAL T1 C+ MR
A series of 6 selected axial T1 C+ MR images through brain
from inferior to superior shows normal meningeal
enhancement at 1.5T. Unlike arachnoid microvessels, dural
microvessels lack capillary endothelial tight junctions. Dural
enhancement is therefore normal following contrast
administration.
The outer and inner dural layers adhere to each other,
except where they encase dural venous sinuses. Venous
flow in sinuses is relatively slow so strong enhancement is
normal. A small arachnoid granulation is present, seen here
as a CSF-intensity filling defect within the strongly
enhancing sinus confluence.
The falx cerebri encases the superior and inferior sagittal
sinuses at its upper and lower margins, respectively. The Y-
shaped tentorial apex is seen very well on this image. Note
inhomogeneous signal within the superior sagittal sinus, a
normal finding.
Normal dural enhancement is thin, smooth, discontinuous,
and symmetric (best appreciated on coronal sections).
Enhancing superficial cortical veins travel within
subarachnoid space before traversing potential subdural
space to drain into dural sinuses. Superficial cortical veins
are typically seen as thicker, more strongly enhancing
structures that branch and communicate with draining
tributaries extending into sulci.
Section through the centrum semiovale shows the falx
cerebri with a prominent inferior sagittal sinus arcing above
the corpus callosum.
Scan through the vertex shows the triangular-shaped
superior sagittal sinus, which is larger posteriorly than
anteriorly. The anastomotic vein of Trolard is seen here as it
courses superiorly from the sylvian fissure toward the
superior sagittal sinus.
1.5T CORONAL T1 C+ MR
First of 3 coronal T1 C+ MR images from posterior to
anterior shows normal dural enhancement at 1.5T following
contrast administration. At this field strength, dura is
thickest near the superior sagittal sinus and typically
appears discontinuous as it sweeps inferiorly. Arachnoid
microvessels have tight junctions and are part of the blood-
brain barrier, which normally does not enhance.
Normal dural enhancement is thin, smooth, and
discontinuous. Enhancement is less intense than adjacent
dural venous sinuses. The falx cerebri and tentorium
cerebelli are dural reflections and therefore also normally
enhance.
Dural enhancement is most prominent near the vertex and
least striking around and under the temporal lobes. Note
that dural enhancement is less intense than the cavernous
sinus.
3T CORONAL T2 MR
First of 6 coronal T2 MR images from posterior to anterior
obtained at 3T shows details of the dura and cortical veins
as they drain into the superior sagittal sinus.
Section through the straight sinus shows its enclosure by
leaves of the falx and tentorium cerebelli. The tentorium
sweeps superiorly from the tops of the petrous ridges and
transverse sinuses to meet the falx cerebri in the midline
and form the straight sinus.
The outer dura and inner table of the skull are tightly
adherent and indistinguishable as a very hypointense black
line, but reflections of the inner (meningeal) dural layer as it
forms the falx cerebri and tentorium cerebelli are easily
seen here.
The tentorial incisura is seen here between the 2 leaves of
the tentorium and transmits the midbrain and basilar artery.
Several perivascular spaces are seen here as linear areas
of high signal intensity within the centrum semiovale. Pia
invaginates along penetrating vessels, forming the
perivascular spaces, which contain interstitial fluid.
Section through the frontal lobes demonstrates attachment
of the falx cerebri to the crista galli. The superior sagittal
sinus is seen here and appears much smaller than on more
posterior sections. The pia covering the cortex is not
distinguishable, even on these high-resolution 3T images.
Selected References
1. Semyachkina-Glushkovskaya, O, et al. Blood⁻brain barrier,
lymphatic clearance, and recovery: Ariadne’s thread in
labyrinths of hypotheses. Int J Mol Sci. 19(12), 2018.
Pia and Perivascular Spaces
Main Text
T ERM INOLOGY
Abbreviations
• Perivascular spaces (PVSs)
Synonyms
• Virchow-Robin spaces (VRSs)

Note: In literature, PVS may sometimes refer to
intramural periarterial drainage pathway, while
"paravascular space" may be used for VRS
Definitions
• Pial-lined, fluid-filled structures that accompany vessels

entering (penetrating arteries) or leaving (draining veins)
cerebral cortex
GROSS ANATOMY
Overview
• Leptomeninges : Thin meninges (arachnoid, pia)

Arachnoid : Translucent, spider-like sheet of tissue
loosely adherent to inner surface of meningeal layer of
dura
Pia : Innermost layer of meninges consisting of thin sheet
(1 or 2 cells thick) covering brain surface
– Pial cells form anatomic barrier between
subarachnoid space (SAS) and brain
– Pia functions as regulatory interface between SAS
and brain (exhibit pinocytosis, enzymatic activity)
• SAS
Cerebrospinal fluid (CSF)-filled space contained between
arachnoid (outer wall), pia (inner wall)
Contains traversing arteries, veins
Numerous filiform trabeculae extend across SAS from
arachnoid to pia, forming bridging chordae coated by
leptomeningeal cells that are continuous with pia, inner
arachnoid
• PVSs
Accompany small and medium-sized arteries as they
penetrate brain parenchyma
Flattened layer of pial cells invaginates along penetrating
arteries
– Basal ganglia and midbrain PVSs contain double
layer of pia; therefore, PVSs are "interpial" space
– Cortex and white matter PVSs lined by single pial
layer; therefore, PVS is between adventitia of vessels
and pia
– PVSs inapparent (even at 7T MR) as they pass
through cortex and become larger in subcortical
white matter
– Pia becomes fenestrated, disappears at capillary level
Fluid composition of PVSs is not completely known
– Interstitial fluid (ISF) may be drained along both
PVSs and intramural compartments
– CSF from SAS may enter PVSs via pores on outer
leptomeningeal sheaths surrounding blood vessels
Most PVSs are 1-2 mm but can become very large
Immunocompetent lymphocytes and monocytes enter
brain via postcapillary venule walls into perivenular
spaces
– Perivenular spaces have discontinuous groups of
pial cells, not complete pial sheath, and are
continuous with subpial space
IMAGING ANATOMY
Overview
• PVSs found in all parts of brain

Most common locations
– Around anterior commissure
– Inferior 1/3 of basal ganglia
– Anterior perforated substance
– Hemispheric white matter (centrum semiovale)
– Midbrain (around substantia nigra)
Other locations
– Extreme capsule
– Subinsular white matter
– Dentate nuclei
• PVSs occur at all ages; prominence/prevalence ↑ with age
• Seen commonly at 1.5T, almost universally on 3T and 7T MR
Usually ≤ 5 mm in size but can be up to 2-3 cm as normal
variant
Appear as round, ovoid, or linear (depending on
orientation of PVSs to plane of section)
– Usually suppress completely on FLAIR (25% have
small hyperintense rim)
– Do not enhance (sometimes linear enhancement of
central vessel can be seen)
– Typically not seen as they pass through cortex; only
become visible as they enter subcortical white matter
– Isointense with CSF on all sequences
Anatomy Relationships
• Pia invaginates along small/medium-sized arteries as they

penetrate brain and create PVSs
• Pia separates SAS from brain parenchyma
Internal Contents
• PVSs are filled with fluid isointense with CSF
Normal Variants, Anomalies
• Giant ("tumefactive") PVSs may cause mass effect,

obstructive hydrocephalus, and mimic neoplasm
Typically occur as clusters of variable-sized, CSF-like
cysts
Suppress on FLAIR; do not enhance
• Widespread enlarged VRSs in white matter may appear
bizarre, but it is very normal variant; usually asymptomatic
• État criblé or status cribrosum is presence of multiple
diffusely widened PVSs in basal ganglia; usually
asymptomatic and symmetric

• FLAIR helpful in distinguishing PVS from lacunar infarct
Imaging Pitfalls
• Prominent PVSs in subinsular white matter and temporal
lobes common; should not be mistaken for
demyelinating/dysmyelinating disorders
• PVSs possibly communicate with SAS via fenestrations and
pores on leptomeningeal lining cells
Some leptomeningeal pathologies, such as
carcinomatosis and infection, may penetrate into VRSs
Subarachnoid hemorrhage does not enter PVSs, even
when extensive
Image Gallery
Print Images
GRAPHICS
Coronal overview shows relationship of the cranial meninges
to the brain and subarachnoid space (SAS). Inner
(meningeal) dural layer and arachnoid are closely but
loosely adherent to each other. Pia (not arachnoid) covers
the cortical surface and accompanies penetrating arteries
through the cortex. CSF-filled SAS is filled with bridging
trabeculae and vessels, all of which are coated with a thin
layer of pial-like cells. Small but numerous dilated
perivascular spaces (PVSs) are seen in the basal ganglia
surrounding lateral lenticulostriate arteries as they pass
cephalad through the anterior perforated substance.
Close-up view shows prominent PVSs clustered in the
inferior 1/3 of the basal ganglia. The PVSs here are
composed of 2 pial layers and are thus an "interpial"
compartment. Focal enlargement at the ends of these PVSs
is common in the basal ganglia.
Close-up view of the cranial meninges and a penetrating
cortical artery is shown. Note that the pia coats vessels and
trabeculae within the SAS and covers the brain surface,
accompanying artery as it penetrates through the cortex.
Pia covering separates the PVSs from the SAS, but
communications via fenestrations and pores between these
2 compartments exist.
A cortical vein is depicted. While a thin sheet of pial-like
cells encases all vessels and trabeculae within the SAS,
only isolated groups of pial cells surround draining cortical
veins. The perivenular spaces (PVeS) are thus in direct
contact with the brain parenchyma.
Interrelationship between arterial (PVS) and venous (PVeS)
PVSs is shown. Fenestrated pial sheath disappears at the
capillary level. Interstitial fluid (ISF) is drained along
periarterial and intramural compartments. Activated
lymphocytes (insert, small arrows) escape from the
postcapillary venule into the surrounding parenchyma.
7T AXIAL T2 MR
First of 3 7T axial T2 MR images from inferior to superior
demonstrates the normal appearance of PVSs in a young
subject. PVSs are seen here in the midbrain. The larger,
high-signal collections just medial to the temporal lobes
represent CSF in a partially fused hippocampal sulcus, a
normal congenital variant, and should not be mistaken for
PVSs or lacunar infarcts.
PVSs are most common along the anterior commissure,
clustered in the inferior 1/3 of the basal ganglia.
PVSs in the deep white matter of the posterior temporal
and occipital lobes appear mostly linear at this level. Some
PVSs may appear larger but are still normal. A few dot-like
PVSs are seen end-on here in the globi pallidi. Note that
even at 7T, the PVSs are not seen as they pass through the
cortex and only become apparent once they reach the
subcortical white matter.
7T CORONAL T2 MR
First of 6 7T coronal T2 MR images from anterior to
posterior demonstrates normal appearance of PVS in a
young patient.
A double layer of pia accompanies penetrating arteries
(here, the lenticulostriate arteries) as they pass cephalad
through the anterior perforated substance into the basal
ganglia, seen especially well in this section. PVSs in the
basal ganglia and midbrain are contained within the 2 pial
layers.
PVSs often occur in clusters, especially in the inferior basal
ganglia and around the anterior commissure. Relatively
fewer PVSs are seen as sections, including the basal
ganglia in front of the anterior commissure. PVSs are still
seen in the centrum semiovale in this image.
Linear-appearing PVSs are seen in the subcortical and
deep white matter but can be detected in the basal ganglia
as well following the penetrating arteries.
A single, somewhat prominent collection of CSF is seen
above the left hippocampus, possibly a choroidal fissure
cyst. A PVS following a lenticulostriate artery is seen.
PVSs are commonly seen in the corona radiata and centrum
semiovale and may normally be quite prominent. At this
level, most are seen as linear streaks of CSF signal
intensity. On FLAIR (not shown), these would suppress
completely.
7T CORONAL AND AXIAL T2 MR

MR scans of variant PVSs are illustrated in this and the
following images. Coronal T2-SPACE 7T MR sequence of
an old patient shows an example of status cribrosum a.k.a.
état criblé. It is a normal variant characterized by multiple
diffusely widened PVSs in the basal ganglia and is usually
asymptomatic.
Axial T2-SPACE 7T MR in the same case shows that many
dot-like PVSs are seen in the right basal ganglia. Some
vessels are visible around the most enlarged PVSs.
Status cribrosum is usually symmetric, but in this specific
case, it is more prominent on the right side.
3T SAGITTAL T1, AXIAL T2, AXIAL FLAIR MR

This series of 3 images compares normal signal intensity of
PVSs on MR. Sagittal T1 MR through an enlarged PVS
demonstrates hypointense fluid signal that is virtually
identical to CSF. Also note the linear penetrating arteries
radiating from the superior margin of PVS.
Axial T2 MR shows that the enlarged PVS has hyperintense
signal similar to CSF in the quadrigeminal cistern and 3rd
ventricle. Multiple other smaller PVSs are seen in the
inferior basal ganglia around the anterior commissure and in
the subinsular white matter.
Axial FLAIR MR shows suppression of fluid signal within
PVSs with a normal signal in the surrounding brain
parenchyma. A thin, hyperintense rim can sometimes be
seen around the PVSs and is a normal finding.
SECT ION 2
SUPRATENTORIAL BRAIN
ANATOMY
Outline

Chapter 15: Premotor Cortex and Supplementary Motor
Area (Area 6)
Chapter 21: Primary Visual and Visual Association Cortex
(Areas 17, 18, 19)
Chapter 27: Parahippocampal Gyrus (Areas 28, 34, 35,
36)
Chapter 31: Primary Auditory and Auditory Association
Cortex (Areas 41, 42)
Cerebral Hemispheres Overview
Main Text
T ERM INOLOGY
Definitions
• Gyri: Complex convolutions of brain cortex

• Sulci (fissure): CSF-filled grooves or clefts that separate gyri
• Operculae: Parts of frontal, temporal, parietal lobes that
overhang/enclose insula
GROSS ANATOMY
Cerebral Hemispheres
• 2 hemispheres, typically of nearly equal size, linked by

commissural fibers
Separated by deep median cleft, great longitudinal
(interhemispheric) fissure
Falx cerebri lies within interhemispheric fissure
• External highly convoluted mantle of cortical gray matter
overlies white matter
• Central sulcus separates frontal, parietal lobes
• Sylvian fissure separates frontal, parietal lobes above from
temporal lobe below
• Deep gray nuclei (basal ganglia, thalami), ventricles centrally
Lobes
• Frontal lobe: Anterior region of hemisphere; anterior to

• Frontal lobe: Anterior region of hemisphere; anterior to
central sulcus, superior to sylvian fissure
• Parietal lobe: Posterior region of hemisphere; posterior to
central sulcus, anterior to parietooccipital sulcus
• Occipital lobe: Posterior to parietooccipital sulcus
• Temporal lobe: Inferior to sylvian fissure, anterior to angular
gyrus
• Insula: Cortical region hidden within depths of lateral
(sylvian) fissure; covered by frontal, temporal, parietal
opercula
IMAGING ANATOMY
Overview
• Frontal lobe
Central sulcus separates frontal, parietal lobes
Precentral gyrus contains primary motor cortex
– Detailed topographically organized map ("motor
homunculus") of contralateral body
– Head/face lateral, legs/feet along medial surface
Premotor cortex: Within gyrus just anterior to precentral
gyrus (motor cortex)
3 additional major gyri: Superior frontal gyrus, middle
frontal gyrus, and inferior frontal gyrus separated by
superior and inferior frontal sulci
• Parietal lobe
Posterior to central sulcus
Separated from occipital lobe by parietooccipital sulcus
(medial surface)
Postcentral gyrus : Primary somatosensory cortex
– Contains topographical map of contralateral body
– Face, tongue, lips are inferior; trunk, upper limb
superolateral; lower limb on medial aspect
Superior and inferior parietal lobules lie posterior to
postcentral gyrus
Supramarginal gyrus lies at end of sylvian fissure
Angular gyrus lies ventral to supramarginal gyrus
Medial surface of parietal lobe is precuneus
• Occipital lobe
Posterior to parietooccipital sulcus
Primary visual cortex on medial occipital lobe
Cuneus on medial surface
• Temporal lobe
Inferior to sylvian fissure
Superior temporal gyrus: Contains primary auditory
cortex
Middle temporal gyrus: Connects with auditory,
somatosensory, visual association pathways
Inferior temporal gyrus: Higher visual association area
Includes major subdivisions of limbic system
– Parahippocampal gyrus on medial surface, merges
into uncus
• Insula
Lies deep in floor of sylvian fissure, overlapped by
frontal, temporal, parietal operculae
Somatosensory function
• Limbic system
Subcallosal, cingulate, parahippocampal gyri
Cingulate gyrus extends around corpus callosum; tapers
rostrally (anteriorly) into paraterminal gyrus, subcallosal
area
Hippocampus, including dentate gyrus, Ammon horn
(cornu ammonis)
• Base of brain
Orbital gyri cover base of frontal lobe: Gyrus rectus
medially
Olfactory bulb/tract lie within olfactory sulcus
• White matter tracts : 3 major types of fibers
Association fibers : Interconnect different cortical
regions in same hemisphere
– Cingulum is long association fiber, which lies
beneath cingulate gyrus
Commissural fibers : Interconnect similar cortical
regions of opposite hemispheres
– Corpus callosum is largest commissural fiber, links
cerebral hemispheres
Projection fibers : Connect cerebral cortex with deep
nuclei, brainstem, cerebellum, spinal cord
– Internal capsule is major projection fiber
• Basal ganglia
Paired deep gray nuclei
Caudate nucleus, putamen, globus pallidus
• Thalamus : Paired nuclear complexes, serve as relay station
for most sensory pathways

• Multiplanar MR best evaluates cerebral hemispheres

• White matter best evaluated by diffusion tensor imaging
(DTI) on 1.5 or 3 Tesla MR
• Limbic system best evaluated with high-resolution coronal
T2 MR, T1 volume images, and FLAIR
• Multiplanar MR best evaluates basal ganglia, thalami
• Diffusion imaging often very helpful for evaluation of
supratentorial disease processes
Image Gallery
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GRAPHICS
Surface anatomy of the cerebral hemisphere, seen from

above, is shown. Gyri and lobules are shown on the left;
sulci on the right. The central (Rolandic) sulcus separates
the posterior frontal lobe from the anterior parietal lobe. The
precentral gyrus of the frontal lobe is the primary motor
cortex, while the postcentral gyrus of the parietal lobe is the
primary sensory cortex. The central sulcus can be reliably
identified on CT and MR imaging.
Inferior view with major sulci and gyri is depicted. Orbital
gyri cover the base of the frontal lobe. The gyrus rectus
(straight gyrus) is most medial. The olfactory bulb/tract (not
shown) lies within the olfactory sulcus. The sylvian (lateral)
fissure separates the frontal lobe from the inferior temporal
lobe. The uncus forms the medial border of the temporal
lobe and merges with the parahippocampal gyrus. The
collateral sulcus separates the parahippocampal gyrus from
the medial occipitotemporal (fusiform or lingual) gyrus.
Lateral surface of the brain depicts major gyri and sulci. The
frontal lobe extends from the frontal pole to the central
sulcus. Supramarginal and angular gyri are part of the
parietal lobe. The supramarginal gyrus has somatosensory
function, while the angular gyrus is important in auditory and
visual input and language comprehension. The superior
temporal gyrus contains the primary auditory cortex and
also forms the temporal operculum. The insular cortex lies
within the sylvian fissure beneath the frontal, temporal, and
parietal opercula.
Sagittal graphic shows the medial view of the cerebral
hemisphere. The corpus callosum represents major
commissural fiber. The fornix and cingulate gyrus are
important in the limbic system. The fornix extends from the
fimbria of the hippocampus posteriorly to the anterior
thalamus, the mammillary body, and the septal region. The
cingulate gyrus is involved with emotion formation and
processing, learning, and memory.
AXIAL CECT
First of 5 axial CECT images of the cerebral hemispheres
from inferior to superior shows the frontal and temporal
lobes and basal ganglia. The anterior limb of the internal
capsule separates the caudate head from the lentiform
nucleus (putamen and globus pallidus). The posterior limb
contains the corticospinal tract and separates the thalamus
from the lentiform nucleus.
More superior image shows parts of the basal ganglia,
including the caudate, putamen, and globus pallidus. The
anterior limb, genu, and posterior limb of the internal
capsule are seen. The internal capsule is major projection
fiber to and from the cerebral cortex, and it fans out to form
the corona radiata. The thalamus borders the 3rd ventricle
and is separated from the basal ganglia by the internal
capsule.
More superior image shows the thalamus and internal
cerebral veins at the level of the lateral ventricles. The falx
cerebri is present within the interhemispheric (great
longitudinal) fissure. The occipital lobe is present
posteriorly, just above the tentorium cerebelli, and contains
the primary visual cortex.
The corona radiata (centrum semiovale) is composed of
radial projection fibers from the cortex to the brainstem. The
corona radiata is continuous with the internal capsule
inferiorly. The occipital lobe is not seen on this and higher
scans.
Image at the cerebral vertex shows the central sulcus
separating the frontal from parietal lobes. The primary
motor cortex is within the frontal lobe precentral gyrus,
while the primary somatosensory cortex is within the
parietal postcentral gyrus. Specific sulci and gyri are better
resolved on MR, although the sylvian fissure and central
sulcus are reliably found on CT.
Axial T1 MR shows functional networks superimposed on
structural neuroanatomy: White = language; light blue =
default network; purple = executive function; deep blue =
limbic system; green = salience/novelty; yellow = attention;
orange = sensory, motor, auditory; red = visual.
3T AXIAL T1 MR
First of 9 axial T1 MR images through the cerebral
hemispheres from inferior to superior shows the inferior
aspect of the hemispheres. The occipital lobe is partially
seen superior to the sloping tentorium cerebelli. The uncus
forms the medial border of the temporal lobe and merges
posteriorly with the parahippocampal gyrus.
Basal aspect of the frontal lobes is formed by orbital gyri.
The olfactory bulb/tract lies in/below the olfactory sulcus.
The hippocampus lies posterior and inferior to the
amygdala. The parahippocampal gyrus is separated from
the medial occipitotemporal (lingual or fusiform) gyrus by
the collateral sulcus.
Axial image at the level of the midbrain shows the sylvian
fissure separating the frontal and temporal lobes. Insula lies
deep to the sylvian fissure covered by surrounding frontal,
temporal, and parietal operculae. The calcarine sulcus is
surrounded by the primary visual cortex in the posterior
occipital lobe.
More superior image at the level of the inferior basal ganglia
shows the anterior limb of the internal capsule separating
the caudate head from the lentiform nucleus. The anterior
commissure is a major commissural fiber, which is seen
anterior to the fornix in the lamina terminales in the anterior
3rd ventricle. The anterior commissure connects the anterior
perforated substance and olfactory tracts anteriorly and the
temporal lobe, amygdala, and stria terminales posteriorly.
This image shows the basal ganglia and thalamus. The
globus pallidus is hyperintense relative to the putamen. The
parietooccipital sulcus separates the parietal and occipital
lobes. The hippocampal tail is seen wrapping around the
midbrain and thalamus. The external capsule lies between
the putamen and claustrum. The extreme capsule lies
between the claustrum and insula.
Image through the superior basal ganglia shows the
supramarginal gyrus and the angular gyrus of the parietal
lobe.
More superior image shows the top of the caudate nucleus
body as it wraps around the lateral ventricle. The
parietooccipital sulcus on the medial aspect of the
hemispheres separates the parietal and occipital lobes.
Cerebral hemispheres are separated by the
interhemispheric (longitudinal) fissure, which contains falx
cerebri. The central sulcus separates the frontal and
parietal lobes. The corona radiata (centrum semiovale) is
formed by fibers from all cortical areas in the internal
capsule fanning out into the superior hemispheres.
More superior image shows falx cerebri within the
interhemispheric fissure. Falx cerebri is a dural fold, which
contains the superior sagittal sinus. The central sulcus
separates the frontal and parietal lobes and is typically
identified on MR. Often, the "hand knob" representing the
hand motor area of the precentral gyrus can be identified
along the posterior margin of the precentral gyrus.
3T CORONAL T1 MR
First of 6 coronal T1 MR images through the cerebral
hemispheres from anterior to posterior shows the genu of
the corpus callosum. The olfactory tract is embedded in the
olfactory sulcus. The olfactory sulcus defines the lateral
margin of the gyrus rectus at the base of the brain.
More posterior image shows the anterior limb of the internal
capsule and anterior commissure. Anteriorly, the caudate
head and putamen are connected. Central regions of the
frontal and temporal lobes are seen. Insula is covered by
frontal and temporal opercula. Superior, middle, and inferior
gyri of the temporal lobe are well seen on coronal imaging
as are superior, middle, and inferior frontal gyri.
This image shows lobulated superior surface of the
hippocampal head. The body of fornix runs below the
corpus callosum. The collateral sulcus separates the
parahippocampal and medial occipitotemporal (fusiform)
gyri.
More posterior image shows the body of the hippocampus
and parahippocampal gyrus forming the medial surface of
the posterior temporal lobe. Lateral geniculate nucleus, a
thalamic nucleus involved in the visual pathway, is seen at
this level. Optic radiations course posteriorly from the
lateral geniculate nucleus to the occipital lobe.
Image at the corpus callosum splenium is shown. The
cingulate gyrus encircles the splenium in an arch to lie
superior and inferior to it. The posterior parahippocampal
gyrus merges with the cingulate gyrus. The posterior sylvian
fissure is visible separating the parietal lobe above from the
temporal lobe below.
More posterior image shows the interhemispheric fissure,
falx cerebri, and tentorium cerebelli. The tentorium cerebelli
is a dural fold in the horizontal plane separating
supratentorial and infratentorial compartments and is
continuous superiorly with falx cerebri.
3T SAGITTAL T1 MR
First of 6 sagittal T1 MR images from lateral to medial
shows the lateral aspect of the sylvian fissure bounded
superiorly by the frontal operculum and inferiorly by the
temporal operculum. The sylvian fissure contains insular
(M2) and opercular (M3) segments of the middle cerebral
artery.
This image shows the central sulcus bordered by precentral
and postcentral gyri. Location of the central sulcus and
precentral gyrus (primary motor cortex) is extremely
important in presurgical planning. The hippocampus is seen
along the temporal horn.
Image through the medial temporal lobe demonstrates the
hippocampus and parahippocampal gyrus. White matter
along the superior margin of the hippocampus represents
fimbria, which curves superiorly and anteriorly beneath the
corpus callosum as fornix, terminating in the mammillary
body. Lateral sulcus (sylvian fissure) separates the
temporal lobe from frontal and parietal lobes.
More medial image shows the central sulcus, bordered
anteriorly by the precentral gyrus (motor cortex) and
posteriorly by the postcentral gyrus (sensory cortex). The
calcarine sulcus and parietooccipital sulcus define the
cuneus of the occipital lobe. The cingulate gyrus extends
around the corpus callosum from the paraterminal gyrus and
subcallosal area rostrally to the parahippocampal gyrus of
the temporal lobe.
Central sulcus separates the frontal and parietal lobes. The
parietooccipital sulcus, located on the medial side of the
hemispheres, separates the parietal and occipital lobes.
Midline sagittal image shows the fornix arching toward the
mammillary body. Cerebral hemispheres are above the
tentorium cerebelli, a dural fold separating the brain into
supratentorial and infratentorial compartments. Cerebral
hemispheres are connected via the corpus callosum, the
largest commissural fiber.
3T AXIAL T2 MR
First of 3 axial T2 MR images from inferior to superior
shows the hippocampus and amygdala. Hippocampal
fissural cysts (hippocampal sulcus remnants), a normal
variant, are noted. The temporal horn separates the
amygdala anteriorly and superiorly from the hippocampus.
More superior image shows the basal ganglia and thalamus.
The putamen is hypointense relative to other deep gray
nuclei related to increased myelin content and iron
deposition in older patients. The globus pallidus is the same
signal intensity as the internal capsule. The anterior limb,
genu, and posterior limbs of the internal capsule are seen.
The anterior limb contains frontopontine fibers and
thalamocortical projections. The genu contains corticobulbar
fibers and the posterior limb contains corticospinal tracts.
Image at the level of the superior thalamus is shown. Nerve
fibers of the corpus callosum radiate into the centrum
semiovale (white matter core) of the hemispheres.
3T CORONAL T2 MR
First of 3 coronal T2 MR images through the limbic system
from anterior to posterior shows the amygdala separated
from the hippocampus by the uncal recess of the temporal
horn. The hippocampal head is recognized by digitations on
its superior surface. The collateral sulcus separates the
parahippocampal gyrus from the occipitotemporal (fusiform)
gyrus.
More posterior image shows the body of the hippocampus
with normal architecture. The body of the fornix arcs over
the thalamus to split into 2 anterior columns, which curve
anteriorly to the foramen of Monro and send fibers to the
mammillary body, anterior thalamus, and septal region.
White matter tracts from the internal capsule are seen
coursing through the cerebral peduncles to the pons.
Image at the posterior thalamus (pulvinar) shows the
hippocampal tail, the smallest portion of the hippocampus.
Fimbria arise from the hippocampus and become the crus
of the fornix, which attaches to the splenium.
Gyral/Sulcal Anatomy
Main Text
IM AGING ANATOM Y
Lobes
• Frontal lobe
Extends to central sulcus
Separated inferiorly & laterally from temporal lobe by
sylvian fissure (a.k.a. lateral sulcus)
• Parietal lobe
Medially separated from occipital lobe by parietooccipital
sulcus
• Temporal lobe: Contains auditory cortex
• Occipital lobe: Holds visual cortex (i.e., V1, V2, V3)
• Insula: Involved in interoception
Covered by lip of cortex: Frontal, parietal, & temporal
opercula
Sulci
• Frontal
Superior & inferior frontal sulci
– Frontal eye field is located at junction of precentral
sulcus & caudal-most part of superior frontal sulcus
Precentral, central, postcentral sulci
Olfactory sulcus
– Contains olfactory bulbs, which transduce & relay
odorant information centrally
Orbital sulcus: H-shaped sulcus separating medial,
anterior, lateral, & posterior orbital gyri
• Parietal
Cingulate sulcus surrounds corpus callosum from
paraterminal gyrus to isthmus
– Marginal branch extends superiorly, lying
immediately posterior to central sulcus
Subparietal sulcus is continuation of cingulate sulcus,
separates precuneus from posterior cingulate gyrus
Parietooccipital sulcus marks boundary between cuneus
& precuneus as well as parietal & occipital lobes
Intraparietal sulcus separates superior & inferior parietal
lobules
– Principal functions: Perceptual-motor coordination
(for directing eye movements and reaching) &
multimodal attention
– Role in processing symbolic numerical information
and visuospatial working memory
• Temporal
Collateral sulcus
– Most mesial temporal sulcus
– Lateral limit of parahippocampal gyrus
Superior, middle, inferior temporal sulci
• Occipital
Occipitotemporal sulcus separates inferior temporal
gyrus, laterally, from occipitotemporal gyrus, mesially
Calcarine separates cuneus from fusiform & lingual gyri
– Primary visual cortex along its banks
Lateral occipital sulcus lies on dorsolateral surface
Lunate sulcus in lateral occipital lobe
Transverse occipital sulcus is anterosuperior limit of
occipital lobe
Gyri
• Frontal
Cingulate gyrus
– Anterior cingulate cortex (CC): Processing of
salience, pain, reward, emotion, & impulse control
– Posterior CC: Self-referential cognition, declarative
memory, & semantic function
– Retrosplenial cortex: Episodic memory & spatial
navigation
Gyrus rectus
Orbital gyri
– Processes response inhibition & representations of
reward, error, emotion, & valuation
Inferior frontal gyrus
– Pars orbitalis
– Pars triangularis & pars opercularis: Broca area
(expressive speech)
Middle frontal gyrus
– Part of dorsolateral prefrontal cortex
– Executive functioning, working memory, attention
Superior frontal gyrus
– Part of premotor cortex; performs initiation &
planning motor control
– Supplementary motor area
Precentral gyrus: Contains primary motor cortex
• Parietal
Postcentral gyrus: Contains somatosensory cortex
Superior parietal lobule
Inferior parietal lobule
– Supramarginal gyrus: Visual word recognition
– Angular gyrus: Semantic language, arithmetic
Precuneus: Medial parietal lobe, above parietooccipital
sulcus
Cingulate gyrus
– Medial surface between corpus callosum & cingulate
gyrus
– Anterior CC, posterior CC (ventral & dorsal),
retrosplenial CC
• Temporal
Inferior temporal gyrus
Middle temporal gyrus
– Hippocampus: Medially located
– Episodic & semantic memories
– Area MT: Motion perception & attention
Superior temporal gyrus
– Planum temporale: Wernicke area (receptive speech)
on surface of superior temporal gyrus
– Transverse temporal gyrus: Primary auditory cortex
Parahippocampal gyrus
– Uncus: Separated from temporal lobe apex by
incisura temporalis, part of primary olfactory area,
contains amygdala
• Occipital
Cuneus: Receives visual information from contralateral
superior retina representing inferior visual field
– Medial occipital lobe, above calcarine fissure
Lingual gyrus: Corresponds to inferior 1/2 of primary
visual cortex, represents contralateral upper quadrant of
binocular visual field
– Medial occipital lobe, below calcarine fissure
Superior, middle, inferior occipital gyri
Medial occipitotemporal gyrus (fusiform gyrus) & lateral
occipitotemporal gyrus
– Part of ventral stream of visual processing,
implicated in processing of faces

• Volumetric T1 MPRAGE, T2 SPACE

Greater spatial & contrast resolution to delineate sulci &
gyri
CLINICAL IMPLICATIONS
Clinical Importance
• Focal lesion in left inferior frontal gyrus (Broca area) →

nonfluent aphasia, slowed speech though appropriate
semantic structure
• Focal lesion in left posterior superior temporal gyrus
(Wernicke area) → unintelligible content though normal
syntax & rhythm
• Lesions of dorsolateral prefrontal cortex → abulia
• Lesion to precentral gyrus → contralateral hemiparesis or
hemiplegia, corresponding to area on somatotopic map
• Orbitofrontal cortex lesion → poor judgment & foresight,
emotional lability, poor interpersonal skills
• Retrosplenial cortex lesion → anterograde amnesia
• Lesion in inferior parietal lobule → neglect syndrome
Image Gallery
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GYRI/SULCI
The central sulcus (CS) divides the frontal & parietal lobes,
lying between the precentral & postcentral gyri. It can be
identified by its inverted omega sign. The frontal lobe
encompasses almost 1/2 of the cerebral hemisphere. The
marginal ramus of the cingulate gyrus resembles a
moustache along the superior surface. It can be used as a
landmark to identify the CS, which lies anterior to it.
The intraparietal sulcus (IPS) meets the postcentral sulcus
as the superior frontal sulcus meets the precentral sulcus in
a "T" shape. The IPS divides the parietal lobe into superior
& inferior parietal lobules. The level of the cingulate gyrus
corresponds to the superior & middle frontal gyri. The IPS is
the dorsal junction of the supramarginal & angular gyri.
The level of the corpus callosum corresponds to the inferior
frontal gyrus. A focal lesion in the left inferior frontal gyrus
(Broca area) yields nonfluent aphasia with slowed speech
but appropriate semantic structure. A focal lesion in the left
posterior superior temporal gyrus (Wernicke area)
produces unintelligible content though with normal syntax &
rhythm.
At the level of the thalamus, the superior temporal gyrus
can be seen. The superior temporal gyrus is marked by 2
obliquely oriented ridges: The transverse temporal gyri,
which constitute the primary auditory cortex, posterior to
which is the planum temporale.
At the level of the midbrain, the middle temporal gyrus
(MTG) is identifiable. The hippocampus lies along the
medial MTG. It is involved in the consolidation of memory &
learning. Procedural memories are preserved even if there
are bilateral hippocampal lesions. The entorhinal cortex also
lies in the medial temporal lobe.
At the level of the pons, the interior temporal gyrus (ITG) is
visible. The MTG and ITG are involved in semantic memory
processing, language processes (MTG), visual perception
(ITG), & integrating information from different senses.
These structures have been implicated in recognizing &
interpreting information about faces & are a part of the
ventral visual pathway that identifies "what" things are. The
ITG also participates in forms of mental imagery.
The inferior parietal lobule is composed of the
supramarginal gyrus (end of the sylvian fissure) & the
angular gyrus (end of superior temporal sulcus). The
supramarginal gyrus functions in word recognition, both
meaning & phonology. The angular gyrus is involved in giving
words meaning. Both areas function in the sequential
performance of tasks. The superior parietal lobule lies
superior to the intraparietal sulcus.
The inferior frontal gyrus is divided into the pars orbitalis,
pars triangularis, & pars opercularis. The pars triangularis &
pars opercularis comprise the Broca area.
The primary visual cortex lies on the margins of the
calcarine fissure in the occipital lobe & is retinotopically
organized. The retina is represented near the occipital pole.
More peripheral regions of the ipsilateral retina &
contralateral visual fields are represented more anteriorly
along the calcarine fissure.
The medial occipitotemporal gyrus (a.k.a. fusiform gyrus) is
important in visual processing, particularly in the processing
of faces. It may also be responsible for differentiating
between closely related objects & familiar objects & the
processing of colors & words.
The gyrus rectus is located in the most medial & inferior
region of the frontal lobe. Its boundaries are the olfactory
sulcus inferiorly & the supraorbital sulcus superiorly. The
olfactory bulb & tract lie in the olfactory sulcus.
The orbitofrontal cortex occupies the ventral surface of the
frontal part of the cerebral hemisphere & is the part of the
prefrontal cortex that receives projections from the
magnocellular medial nucleus of the mediodorsal thalamus.
This region receives inputs from all the sensory modalities:
Gustatory, olfactory, somatosensory, auditory, & visual. It
functions in evaluating the reward value of tastes & odors.
Damage to the orbitofrontal cortex can impair face & voice
expression identification as well as the learning & reversal
of stimulus-reinforcement associations.
The hippocampal formation is composed of the
hippocampus, dentate gyrus, & associated white matter:
Alveus, fimbria, & fornix. The entorhinal cortex is present
along the length of the parahippocampal gyrus. The
subiculum is a transitional zone between the entorhinal &
hippocampal cortices.
The lateral sulcus defines the superior temporal lobe
border, which is composed of the superior, middle, &
inferior temporal gyri. The occipitotemporal sulcus
separates the medial border of the inferior temporal gyrus
from the lateral border of the fusiform gyrus. Medial to the
fusiform gyrus is the collateral sulcus, and medial to the
collateral sulcus, the parahippocampal gyrus forms the
medial border of the inferior surface of the temporal lobe.
Axial T1 MR shows functional networks superimposed on
structural neuroanatomy. White = language; light blue =
default network; purple = executive function; deep blue =
limbic system; green = salience/novelty; yellow = attention;
orange = sensory, motor, auditory; red = visual.
Right hemispheric surface-rendered view in lateral (top),
medial (middle), superior (bottom left), and inferior (bottom
right) projections was obtained from a single subject. Image
was constructed in FreeSurfer using the Desikan-Killiany
atlas.
Left hemispheric surface-rendered view in lateral (top),
medial (middle), superior (bottom left), and inferior (bottom
right) projections was obtained from a single subject. Image
was constructed in FreeSurfer using the Desikan-Killiany
atlas.
Additional Images
Right hemispheric surface-rendered view in lateral (top left),
medial (top right), superior (bottom left), and inferior
(bottom right) projections was obtained from a single
subject and constructed in FreeSurfer via the Desikan-
Killiany atlas.
Left hemispheric surface-rendered view in lateral (top left),
medial (top right), superior (bottom left), and inferior
(bottom right) projections was obtained from a single
subject and constructed in FreeSurfer via the Desikan-
Killiany atlas.
White Matter Tracts
Main Text
GROSS ANATOM Y
Overview
• Hemispheric white matter tracts divided by course into

association, commissural, projection fibers
• Association fibers (may be short or long)
Short (arcuate or "U" fibers) link adjacent gyri, course
parallel to long axis of sulci
Long fibers form fasciculi connecting widely spaced gyri
– Cingulum : Long, curved fasciculus deep to
cingulate gyrus; interconnects parts of
frontal/parietal/temporal lobes
– Uncinate fasciculus : Connects motor speech area &
orbital gyri of frontal lobe with temporal lobe cortex
– Superior longitudinal (arcuate) fasciculus :
Connects frontal to parietal, temporal, & occipital
cortex
– Inferior longitudinal fasciculus : Connects temporal
& occipital cortex, contributes to sagittal stratum
– Superior occipitofrontal fasciculus : Connects
occipital & frontal lobes, lies beneath corpus
callosum (CC)
– Inferior occipitofrontal fasciculus : Connects
occipital & frontal lobes inferiorly; posteriorly forms
sagittal stratum, which connects occipital lobe to
rest of brain
• Commissural fibers
CC
– Largest commissure; links hemispheres
– 4 parts: Rostrum, genu, body, splenium
– Rostral fibers extend laterally connecting orbital
surfaces of frontal lobes
– Genu fibers curve forward as forceps minor, connect
lateral/medial frontal lobes
– Body fibers pass laterally, intersect with projection
fibers of corona radiata with widespread
connectivity
– Tapetum: Formed by body, some splenium fibers;
course around posterior & inferior lateral ventricles
– Most splenium fibers curve into occipital lobes as
forceps major
Anterior commissure
– Transversely oriented, compact, myelinated bundle
– Crosses anterior to fornix, embedded in anterior wall
of 3rd ventricle
– Splits into 2 bundles laterally
– Anterior bundle to anterior perforated substance,
olfactory tract
– Larger posterior fans out into temporal lobe
Posterior commissure : Small; courses transversely in
posterior pineal lamina to connect midbrain,
thalamus/hypothalamus
• Projection fibers
Corona radiata : Fibers from internal capsule fan out to
form corona radiata, represent all cortical areas
Internal capsule : Major conduit of fibers to/from
cerebral cortex
– Anterior limb: Frontopontine fibers, thalamocortical
projections
– Genu: Corticobulbar fibers
– Posterior limb: Corticospinal tracts, upper limb-
anterior, trunk, & lower limbs-posterior
Corticospinal tract : Major efferent projection fibers
connect motor cortex to brainstem, spinal cord
– Converge into corona radiata, continue through
posterior limb of internal capsule to cerebral
peduncle & lateral funiculus
Corticobulbar tract : Major efferent projection fibers
connect motor cortex to brainstem & spinal cord
– Converge into corona radiata to genu of internal
capsule to cerebral peduncle, terminate in motor
cranial nerve nuclei
Corticopontine tract : Motor information to pons
Corticothalamic tract : Connects entire cerebral cortex
with isotopic location in thalamus
IMAGING ANATOMY
Overview
• Myelination generally proceeds inferior to superior; central

to peripheral; posterior to anterior
• MR signal depends on maturation
• Fully myelinated white matter hyperintense on T1WI,
hypointense on T2WI
White Matter Maturation
• Occurs at different rates, times on T1/T2 imaging

Up to 6 months, T1WI most useful
After 6 months, T2WI is most useful
• Newborn
T1WI: Newborn brain resembles T2 image in adult
– White matter has lower signal than gray matter
– With maturation, intensity of white matter increases
T2WI: Newborn brain resembles T1 image in adult
– White matter has higher signal than gray matter
– T2 superior for evaluating cerebellum & brainstem
maturation
• First 6 months
T1WI
– 3 months: High signal in anterior limb, internal
capsule, & cerebellar folia
– 4 months: High signal in CC splenium
– 6 months: High signal in CC genu
– 8 months: Near adult appearance, except most
peripheral fibers
• 6-18 months
T2WI signal
– 6 months: Low in CC splenium
– 8 months: Low in CC genu
– 11 months: Low in anterior limb, internal capsule
– 14 months: Low in deep frontal white matter
– 18 months: Near adult appearance, except most
peripheral fibers
Disorders of Corpus Callosum
• Agenesis of CC is congenital disorder of interhemispheric

connections
Conditions include complete agenesis (absent CC),
hypogenesis (partial CC), hypoplasia (thin CC),
dysgenesis (malformed CC)
• Callosal disorders are readily visualized in sagittal midline
slices of T1WI & DTI
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GRAPHICS
Sagittal graphic shows midline white matter tracts. Corpus

callosum (CC), the largest commissure, connects
corresponding areas of cortex between hemispheres.
Fibers traversing the CC body are transversely oriented,
while those traversing the CC genu & splenium arch
anteriorly & posteriorly to reach anterior & posterior poles
of hemispheres. Cingulum, an association fiber, starts in the
medial cortex below the CC rostrum, courses within
cingulate gyrus, arches around the CC, & extends forward
to the parahippocampal gyrus & uncus.
Graphic shows the superior view of the largest white matter

fiber bundle, CC, which connects corresponding areas of
cortex between hemispheres. Close to the midline, CC
fibers are primarily left-right oriented. More laterally, CC
fibers fan out & intermingle with projection & association
tracts.
Sagittal graphic shows major projection fibers, which
interconnect cortical areas with deep nuclei, brainstem,
cerebellum, & spinal cord. There are both efferent
(corticofugal) & afferent (corticopetal) projection fibers.
Efferent fibers converge from all directions to form a dense
subcortical white matter mass of corona radiata. The
corona radiata is continuous with the internal capsule, which
contains the majority of cortical projection fibers. The major
projection fibers of the internal capsule include corticospinal,
corticobulbar, & corticopontine tracts. Optic radiations
extend from the lateral geniculate nucleus to the occipital
lobe.
Sagittal graphic laterally shows association fibers, which
interconnect cortical areas in each hemisphere. The
superior longitudinal fasciculus is the largest association
bundle & connects the frontal lobe to parietal, temporal, &
occipital lobe cortices.
3T DIFFUSION MR TRACTOGRAPHY: HEALTHY ADULT

First of 2 tractography renderings shows the 3D geometry
of white matter pathways. Above are fibers obtained from
cropping whole-brain tractography at the midline to reveal a
variety of pathways, including the CC, cingulum, fornix,
middle cerebellar peduncle, cerebral peduncle, medial
lemniscus, inferior cerebellar peduncle, & corona radiata.
3D rendering of a tractography model shows a lateral view
of the CC. The fibers are colored to differentiate cortical
targets, which include occipital, parietal, motor, premotor,
supplementary motor, & prefrontal cortices.
3D rendering of a tractography model shows a superior
view of the CC. The fibers are colored to differentiate
cortical targets, which include occipital, parietal, motor,
premotor, supplementary motor, & prefrontal cortices.
First of 2 tractography images shows the 3D geometry of
white matter tracts and a portion of the superior longitudinal
fasciculus. These pathways facilitate language processing
by communicating information between the Broca area in
the inferior frontal lobe, Wernicke area in the posterior
section of the superior temporal lobe, & Geschwind territory
in the inferior parietal lobe.
Tractography model shows white matter connections of the
limbic system. The uncinate, the cingulum bundle, & the
fornix, which partly comprise the Papez circuit, are shown.
The fornix is shown to connect the superior aspect of the
hippocampus to other brain areas, & the cingulum is shown
to connect the inferior aspect to the parietal & frontal lobes.
The uncinate is shown to further connect the temporal &
frontal lobes structures, forming a circuit with the cingulum.
First of 3 tractography images shows the 3D geometry of
white matter tracts, as well as the thalamic radiations &
uncinate fasciculus.
Tractography model of the inferior longitudinal fasciculus,
inferior occipitofrontal fasciculus, corona radiata, &
corticospinal tract illustrate the separation of internal &
external capsule pathways.
Tractography model shows the external capsule pathways,
including the inferior occipitofrontal fasciculus & the
claustrocortico projections.
3T AXIAL DTI: TYPICAL ADULT

First of 3 axial DTI slices showing white matter tracts, taken
at a level superior to the CC, is shown. DTI directional color
encoding enables the visualization of distinct pathways that
would otherwise appear homogeneous on T1WI & T2WI.
The corona radiata, cingulum, & superior longitudinal
fasciculus are shown.
Slice at the level of the thalamus shows white matter tracts.
The internal & external capsules are shown, with the
anterior thalamic radiation through the anterior limb & the
corticospinal tract through the posterior limb. Connections of
the CC are also shown, including the forceps minor, which
connects the frontal lobes through the genu, the forceps
major, which connects the occipital lobes through splenium,
& the tapetum, which connects the temporal lobes through
the body.
Slice at the level of the brainstem is shown. The middle
cerebellar peduncle is shown connecting the hemispheres of
the cerebellum. Also shown are the inferior cerebellar
peduncle, medial lemniscus, pontine crossing tract, & the
cerebral peduncle, including the corticospinal tract.
3T CORONAL DTI: TYPICAL ADULT

First of 3 coronal DTI slice showing white matter tracts,
taken at the level of the anterior commissure, is shown. DTI
directional color encoding enables the visualization of
distinct pathways that would otherwise appear
homogeneous on T1WI & T2WI. The internal capsule,
thalamic radiation, corona radiata, fornix, cingulum, & other
association pathways are also shown.
Slice at the level of the hippocampus shows the fornix,
internal & external capsules, the hippocampal connections
of the cingulum, & other pathways.
Slice taken posteriorly shows the layering of the tapetum &
thalamic radiations, as well as their relation to the nearby
inferior occipitofrontal fasciculus & inferior longitudinal
fasciculus. The superior longitudinal fasciculus is also shown
as it curves from its longitudinal aspect inferiorly into the
temporal lobe.
3T SAGITTAL DTI: TYPICAL ADULT

First of 3 sagittal DTI slices shows white matter tracts,
taken at the midline. DTI directional color encoding enables
the visualization of distinct pathways that would otherwise
appear homogeneous on T1WI & T2WI. The CC, anterior
commissure, cingulum bundle, & brainstem pathways are
also shown.
Slice at the level of the hippocampus shows the fornix,
hippocampal portion of the cingulum, forceps major, inferior
longitudinal fasciculus, & middle cerebellar peduncle. The
close relationship of the inferior occipitofrontal fasciculus,
inferior longitudinal fasciculus, & uncinate fasciculus in the
external capsule is shown as well.
Slice taken laterally shows the inferior longitudinal
fasciculus, fornix, posterior thalamic radiation, middle
cerebellar peduncle, & superior longitudinal fasciculus. The
close relationship of the inferior occipitofrontal fasciculus &
uncinate fasciculus in the external capsule is shown as well.
3T AXIAL T1 MR: 32 WEEKS PREMATURE

First of 3 axial T1 MR images from inferior to superior of a
normal 32-week premature infant shows posterior fossa
structures. Superior & inferior cerebellar peduncles are
bright on T1, but middle cerebellar peduncles remain
unmyelinated, isointense to cerebral white matter, & dark on
T1. The dorsal brainstem is relatively hyperintense on T1
compared with the ventral pons.
Image at the level of the internal capsule shows that the
internal capsule is hypointense compared with lentiform
nucleus. Sylvian fissures remain prominent. White matter is
hypointense related to lack of myelination.
Image at the level of the corona radiata shows the white
matter as completely unmyelinated with a T1-hypointense
appearance. Sulci are prominent related to immaturity.
Signal intensity of the entire cerebral cortex is uniform on
T1WI & T2WI.
3T AXIAL T2 MR: 32 WEEKS PREMATURE

normal 32-week premature infant shows posterior fossa
structures. Dorsal (posterior) brainstem is relatively
hypointense (dark) on T2 compared with unmyelinated
ventral (anterior) pons. The superior & inferior peduncles
are hypointense on T2. The middle cerebellar peduncle is
hyperintense on T2, similar to cerebral white matter.
Image at the level of the internal capsule shows that the
thalamus & basal ganglia are hypointense (dark). The
internal capsule is typically hyperintense at this age although
difficult to differentiate in this case. T2 also shows
hypointensity in the far lateral putamen & ventrolateral
thalamus at this premature age.
Image through the corona radiata shows unmyelinated white
matter, hyperintense compared with gray matter.
3T AXIAL T1 MR: BIRTH

normal full-term infant at birth shows posterior fossa
structures. The superior & inferior cerebellar peduncles are
bright on T1, but middle cerebellar peduncles remain
unmyelinated, isointense to cerebral white matter, & dark on
T1. The dorsal brainstem is relatively hyperintense on T1
compared with the ventral brainstem.
Image at the level of the internal capsule shows
hyperintensity of the posterior limb compared with the
anterior limb. The lateral thalamus is also bright compared
with the remainder of the thalamus.
Image through the corona radiata shows increased signal
intensity in rolandic (precentral) & perirolandic gyri
corresponding to known myelination within these gyri at or
shortly after birth. Reminder of cerebral white matter
remains hypointense, related to a lack of myelination.
3T AXIAL T2 MR: BIRTH

normal infant at birth shows posterior fossa structures. At
birth, low signal is present in the inferior & superior
cerebellar peduncles. The cerebellar vermis is also low
signal compared with the rest of the cerebellum. T2 imaging
is more sensitive for evaluation of posterior fossa structure
maturation.
Image at the level of the internal capsule shows a small
patch of hypointensity within the posterior limb of the
internal capsule & within the lateral putamen. The ventral
lateral region of the thalamus is also hypointense (dark) at
birth. The CC is unmyelinated at birth & matures in a
posterior to anterior fashion.
Image at the corona radiata shows predominantly
unmyelinated white matter, hyperintense compared with
gray matter. Subtle hypointensity in the cortex of pre- &
postcentral gyri can be seen & is normal.
3T AXIAL T1 MR: 3 MONTHS

normal infant at 3 months shows posterior fossa structures.
The cerebellum has a nearly adult appearance by 3 months.
The dorsal brainstem remains slightly hyperintense
compared with the ventral brainstem.
Image at the level of the internal capsule shows high signal
in the posterior limb & early, subtle high signal in the
anterior limb of the internal capsule. The CC remains
unmyelinated, but the splenium will show high signal by ~ 4
months. The deep white matter begins myelinating ~ 3
months, appearing first in the deep occipital white matter.
Image through the corona radiata shows predominantly
unmyelinated white matter, hypointense compared with gray
matter. Deep white matter matures in a posterior to anterior
direction, & early maturation is seen posteriorly.

normal infant at 3 months shows posterior fossa structures.
Low signal intensity is noted in cranial nerve nuclei, including
abducens CNVI, facial CNVII, & vestibulocochlear CNVIII.
The dorsal brainstem is mildly hypointense compared with
the ventral brainstem & becomes isointense at ~ 5 months.
The middle cerebellar peduncles are low signal by 3
months.
Image at the level of the internal capsule shows hypointense
(dark) signal in the posterior limb of the internal capsule.
The internal capsule matures in a posterior to anterior
fashion. The CC & deep & subcortical white matter remains
unmyelinated.
Image through the corona radiata shows predominantly
unmyelinated white matter, hyperintense compared with
gray matter. Newborn white matter on T2 resembles an
adult on T1.

normal 6 month old shows posterior fossa structures. The
cerebellum has an adult appearance by 3 months. Signal
intensity in the ventral (anterior) pons is bright with an adult
appearance at this age.
hyperintensity (bright) in the genu & splenium of CC. The
internal capsule is hyperintense throughout. At birth, only the
posterior limb is bright, but by 3 months, the anterior limb is
also bright.
Image through the corona radiata shows progressive
maturation of white matter with increasing hyperintensity of
the subcortical white matter, notably in occipital & parietal
regions. The deep white matter matures in a posterior to
anterior direction with deep occipital white matter maturing
first, & frontal & temporal white matter last.

ventral brainstem becomes similar to the dorsal brainstem
at ~ 5 months & is similar throughout the pons in this case.
The cerebellar peduncles are hypointense, similar to an
adult patient by ~ 4 months.
Image at the level of the internal capsule shows a dark
posterior limb relative to an anterior limb. The internal
capsule matures in a posterior to anterior fashion. The CC
also matures in a posterior to anterior fashion. The splenium
is hypointense (dark) compared with genu of the CC.
Image at the level of the corona radiata shows a relative
decrease of signal in deep white matter. The subcortical
white matter matures last, beginning in the posterior
occipital lobes & extending anteriorly to the frontal &
temporal lobes.

brainstem & cerebellum have an adult appearance. The
temporal lobe white matter remains unmyelinated.
Image at the level of the internal capsule shows a near adult
appearance on T1. White matter of the internal capsule &
CC is hyperintense compared with the basal ganglia &
thalamus, similar to an adult. The deep & subcortical white
matter of the frontal lobes appears unmyelinated compared
with the occipital lobes.
Image through the corona radiata shows further myelination
of deep & subcortical white matter. Frontal & temporal lobe
white matter is last to completely myelinate & appear
slightly hypointense compared with parietal lobe white
matter. Only minimal changes are seen in the white matter
after 8 months on T1.

cerebellum begins to develop low signal in the white matter
of the cerebellar folia (arborization) by 8 months but does
not reach an adult appearance until ~ 18 months.
hypointensity in the anterior & posterior limbs. The anterior
limb continues to thicken until ~ 10 months. The CC is
myelinated by ~ 8 months.
Image through the corona radiata shows partial myelination
of deep & subcortical white matter, proceeding from the
occipital region anteriorly to the frontal & temporal lobes.
Myelination of the subcortical white matter begins at ~ 9-12
months in the occipital lobes. The temporal lobe white
matter matures last.

cerebellum has an adult appearance. Signal intensity in the
ventral (anterior) pons is bright as in an adult. Only temporal
lobe white matter remains immature.
Image at the level of the internal capsule shows an adult
appearance on T1. The white matter of the internal capsule
& CC is hyperintense compared with the basal ganglia &
thalamus. The globus pallidus is distinguishable as slightly
hyperintense compared with the putamen located laterally.
Image at the level of the corona radiata shows an adult
appearance of the deep white matter & a near adult
appearance of the subcortical white matter. The subcortical
white matter matures last, beginning in the posterior
occipital lobes & extending anteriorly to the frontal &
temporal lobes.

normal 12 month old shows posterior fossa structures.
Arborization of the cerebellum, low signal in the cerebellar
folia subcortical white matter, begins at 6-8 months but is
not complete until 18 months. The temporal white matter
remains immature.
Image at the level of the internal capsule shows dark
anterior & posterior limbs by 12 months. The basal ganglia
& thalamus appears dark relative to the white matter. The
cortex & underlying white matter are essentially isointense
throughout most of brain at this age, making T1 images
better for identifying structural abnormalities.
Image at the level of the corona radiata shows increased
dark signal in the white matter of the paracentral & occipital
regions. White matter maturation occurs in the occipital
regions first & moves anteriorly.

Posterior fossa structures have an adult appearance on T1.
Temporal & frontal lobe white matter is last to myelinate but
has an adult appearance on T1 by 11-12 months.
appearance of the basal ganglia, thalamus, & white matter.
The CC has an adult appearance on T1 by 6 months, while
the internal capsule has an adult appearance by 3 months.
Image at the level of the corona radiata shows an adult
appearance with hyperintensity seen in the deep white
matter & subcortical white matter. Myelination has an adult
appearance in the white matter on T1 by 11-12 months &
an adult appearance on T2 by 18 months.

Posterior fossa structures, including the brainstem &
cerebellum, have an adult appearance. The cerebellum
reaches an adult appearance on T2 by 18 months. The
temporal lobe subcortical white matter is last to mature &
reaches full maturity by 22-24 months.
appearance of the CC & internal capsule. The white matter
of the frontal & temporal lobes is last to appear mature on
T2 & remains relatively hyperintense, particularly in the
temporal lobes.
Image at the level of the corona radiata shows further
hypointensity in the deep & subcortical white matter.
Although somewhat patchy, subcortical white matter is
hypointense in the majority of the brain.
3T AXIAL T1 MR: 3 YEARS

normal 3 year old shows an adult appearance. Cerebellar
folia maturation, arborization, occurs much earlier on T1
than T2. The cerebellum appears mature on T1 by ~ 3
months. However, maturation of the brainstem & cerebellum
is more sensitively assessed on T2 MR.
appearance of the internal capsule, CC, & deep gray nuclei,
including the basal ganglia & thalamus. The temporal lobe
subcortical white matter is last to appear mature at ~ 11-12
months on T1.
Image at the corona radiata shows an adult appearance of
the deep & subcortical white matter. Although conventional
MR imaging suggests an adult appearance by 2 years,
functional studies suggest that complete myelination is not
achieved until adolescence.
3T AXIAL T2 MR: 3 YEARS

First of 3 axial T2 MR images in a normal, mature 3 year
old shows an adult appearance of posterior fossa
structures. The temporal lobe subcortical white matter is
also mature.
Image at the level of the internal capsule shows a near adult
appearance in this 3 year old patient. The globus pallidus
becomes more hypointense at ~ 10 years related to normal
iron deposition.
Image at the level of the corona radiata shows a normal
adult appearance of the deep & subcortical white matter.
The corona radiata is formed by fibers from all cortical
areas, which fan out from the internal capsule. T2 MR
imaging is superior for evaluating brain maturation after 6
months of age. A normal adult appearance is usually
obtained by 18 months, except for most peripheral fibers.
3T CORONAL STIR MR
First of 3 coronal STIR MR images through the white matter
tracts from anterior to posterior is shown. The anterior
commissure crosses through the lamina terminalis. The
anterior fibers of the anterior commissure connect the
olfactory bulbs & nuclei while posterior fibers connect the
middle & inferior temporal gyri. The anterior limb of the
internal capsule lies between the head of the caudate &
lentiform nucleus & passes projection fibers to/from the
thalamus (thalamocortical projections) & frontopontine
tracts.
Image more posterior shows the body of the fornix. The
fornix is a major white matter tract associated with the
hippocampus & limbic system.
Image taken posteriorly shows the splenium of the CC &
crus of fornix. The hippocampal fimbria continue along the
undersurface of the splenium to form the crus of fornix,
which extend under the body of the CC to form the
commissure, which becomes the body anteriorly.
3T MP-RAGE T1 MR: PARTIAL AGENESIS OF C ORPUS

CALLOSUM
First of 3 T1 MR slices depicting partial agenesis of the CC
is shown. The coronal slice shows an absent portion of the
CC.
Axial slice shows abnormalities in the posterior portion of
the body of the CC.
Sagittal slice shows partial agenesis of the CC, specifically
an absent posterior portion of the body of the CC.
3T DTI: PARTIAL AGENESIS OF CORPUS CALLOSUM

First of 3 images shows a partial agenesis of the CC. The
coronal slice shows the absent callosal fibers at the midline,
which are typically colored red to indicate a left-right fiber
orientation of the callosal diffusion tensor models.
Sagittal slice shows partial agenesis of the CC, specifically
an absent posterior portion of the body of the CC.
DTI tractography reconstruction, cropped at the midline to
show the CC, is depicted. The image shows the absent
posterior portion of the body of the CC & an intact cingulum
bundle.
Basal Ganglia and Thalamus
Main Text
T ERM INOLOGY
Definitions
• Basal ganglia (BG): Subcortical nuclear masses in inferior

hemispheres
Involved in motivation, controlling movement
Lentiform nucleus: Putamen + globus pallidus (GP)
Corpus striatum: Caudate nucleus + putamen + GP;
neostriatum = putamen, caudate
Definition recently narrowed to exclude claustrum,
amygdala
• Thalamus: Paired ovoid nuclear complexes; relay stations for
most sensory pathways
• Subthalamus: Complex region of nuclear masses, fiber tracts
that plays major role in normal BG function
GROSS ANATOMY
Overview
• BG : Caudate nucleus, putamen, GP

Anterior limb of internal capsule separates caudate head
from putamen, GP
Posterior limb separates thalamus from BG
• Caudate nucleus : C-shaped curved nucleus with large
head, tapered body, down-curving tail
Head forms floor/lateral wall of anterior horn of lateral
ventricle
Body borders, parallels lateral ventricle
Tail follows curve of inferior horn, lies in ventricular roof
Deep groove (sulcus terminalis) separates caudate from
thalamus; its stria terminalis lies deep to ependyma,
helps form choroid fissure
Caudate continuous anteriorly with inferior putamen
above anterior perforated substance; with
posteroinferior putamen at caudate tail
• Putamen : Located lateral to GP, separated by lateral
(external) medullary lamina
• GP : 2 segments
Lateral (external), medial (internal) segments separated
by internal medullary lamina
Higher myelin content than putamen (darker on T2)
• Thalamus : Ovoid nucleus, extends from foramen of Monro
to quadrigeminal plate of midbrain
Medially forms lateral walls of 3rd ventricle
Laterally bordered by internal capsule
Subdivided into nuclear groups (anterior, medial,
lateral), geniculate nuclei (lateral, medial), pulvinar
– Nuclear groups further subdivided into 10 additional
nuclei
– Internal medullary lamina separates medial, lateral,
anterior nuclear groups
– External medullary lamina separates lateral nuclear
group, reticular nucleus
Geniculate nuclei
– Lateral geniculate nucleus: Ovoid ventral projection
from posterior thalamus (part of visual system)
– Medial geniculate nucleus: Medial to lateral
geniculate nucleus along posterior thalamus (part of
auditory system)
Pulvinar: Occupies caudal 1/3 of thalamus & overhangs
superior colliculus
Massa intermedia (interthalamic adhesion): Connects
thalami across 3rd ventricle
• Subthalamus
Associated with Parkinson disease, ballism
Subthalamic, reticular nuclei included
Subthalamic nucleus is lens-shaped, lies superolateral to
red nucleus
Reticular nucleus: Lamella that wraps around lateral
thalamus, separated from it by external medullary
lamina
Vascular Supply
• BG: Mostly lenticulostriate arteries

• Thalamus: Mostly thalamoperforators from posterior
communicating, basilar, P1 posterior cerebral arteries
Large thalamoperforator (artery of Percheron or
paramedian thalamic artery) may supply bilateral medial
thalami
IMAGING ANATOMY
Overview
• CT: Deep gray nuclei hyperdense to white matter; isodense

with cortex
Punctate or dense globular Ca⁺⁺ common
Usually symmetric, in medial GP
Common in middle-aged, older patients
• MR
Iron deposition in BG occurs with normal aging
– No iron in brain at birth
– Progressive ↑ with aging, ↓ signal intensity on T2WI
– GP hypointensity begins to ↑ in 2nd decade, plateaus
after age 30
– Putamen = GP hypointensity at 80 years

• MR (axial, coronal) best general imaging; NECT for Ca⁺⁺

• DWI, T2* helpful additions
Clinical Importance
• Disorders of BG are characterized by abnormalities of

movement, muscle tone, & posture
• Putamen is most common location affected by hypertensive
hemorrhage
• GP is most sensitive area of brain to hypoxia (in addition to
hippocampus)
• BG is common location for strokes, particularly lacunar
infarcts & hypertensive hemorrhages
Image Gallery
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GRAPHICS
Coronal graphic of the basal ganglia at the level of the
anterior commissure & frontal horns of the lateral ventricles
is shown. The caudate head lies along the lateral wall of the
frontal horn & is separated from the globus pallidus (GP) &
putamen by the anterior limb of the internal capsule. The
external medullary lamina separates the putamen from the
GP. The GP has 2 segments, a lateral & medial segment,
separated by the internal medullary lamina (not shown).
Coronal graphic of the basal ganglia & thalamus through the
anterior 3rd ventricle shows division of the thalamic nuclei
into 3 main groups: The lateral nuclei, medial nuclei, &
anterior nuclei. The internal medullary lamina separates
these main thalamic groups. These main thalamic nuclear
groups cannot be resolved by conventional imaging.
Coronal graphic of the basal ganglia at the level of the
frontal horns of the lateral ventricles shows vascular supply
from anterior circulation. Note that the medial lenticulostriate
arteries supply the head of caudate, anterior portions of the
putamen, GP, & the anterior limb of the internal capsule,
while lateral lenticulostriate arteries supply the majority of
the GP, putamen, & internal capsule. Note the lack of
collateral supply to the basal ganglia.
Axial graphic of the basal ganglia & thalamus shows the
internal capsule separating the caudate & thalamus from the
putamen & GP. The anterior limb primarily contains fibers
from the frontal lobes. Genu of the internal capsule contains
corticobulbar fibers & thalamic fibers, while the posterior
limb contains corticospinal tracts & thalamic fibers. Fibers
from the upper extremity are anterior within the posterior
limb, while lower extremity fibers are posterior.
AXIAL CECT
First of 3 CECT images of the basal ganglia & thalamus
from inferior to superior is shown. Note the internal capsule
appears hypodense & helps separate the caudate head
from the putamen & GP. The external capsule, claustrum, &
extreme capsule cannot be resolved on CT imaging.
Unenhanced CT is an excellent choice for the initial
evaluation of a possible basal ganglia stroke, as
hypertensive hemorrhages & lacunar infarcts are common in
the basal ganglia & thalami & are well seen by CT.
This image shows a large anterior caudate head lying in the
floor & lateral wall of the frontal horn of the lateral ventricle.
The putamen & GP are separated on CT by location &
subtle differences in density. The GP is often slightly less
dense than the putamen.
Image more superior shows the thalamus as it extends
posteriorly. The massa intermedia (interthalamic adhesion)
connects the thalami across the 3rd ventricle.
3T AXIAL T1 MR
shows the inferior aspect of the basal ganglia & thalamus.
Note the caudate head lies inferior to the frontal horns of
the lateral ventricles at this level.
Image thorough the basal ganglia & thalamus shows distinct
nuclei of the caudate, putamen, & GP. Note the massa
intermedia (interthalamic adhesion) across the 3rd ventricle.
The habenula (which connects olfactory impulses to
brainstem nuclei) is seen at this level. Lateral to the
putamen, the external capsule, claustrum, extreme capsule,
& insular cortex are present.
This image shows the internal capsule in its entirety with the
anterior limb, genu, & posterior limb. The genu of the
internal capsule contains corticobulbar fibers & thalamic
fibers, while the posterior limb contains corticospinal tracts
& thalamic fibers. The lenticulostriate arteries supply the
internal capsule.
Image more superior through the basal ganglia at the level
of the genu & splenium of the corpus callosum is shown.
The head & tail of the caudate nucleus are seen as the
caudate curves around the lateral ventricle. The tail of the
caudate lies in the ventricular roof in the temporal lobe. The
caudate is separated from the thalamus by the sulcus
terminalis, which contains stria terminalis & thalamostriate
veins anteriorly. The putamen is larger than the GP &
continues more superiorly.
Image at the level of the centrum semiovale shows the head
& body of the caudate as it wraps around the lateral
ventricle. The caudate nucleus lies in the frontal lobe &
wraps around the ventricle to end in the temporal lobe at
the amygdala.
Image more superior shows the body of caudate head as it
parallels the lateral ventricles.
3T CORONAL T1 MR
First of 6 coronal T1 MR images from anterior to posterior
through the basal ganglia & thalamus is shown. Note the
inferior part of the caudate head becomes continuous with
the most inferior part of the putamen just above the anterior
perforated substance.
Image at the level of the anterior commissure shows the
anterior limb of the internal capsule as it separates the
caudate head from the putamen & GP. The GP & putamen
have different signal intensity related to increased myelin in
the GP. The lateral & medial segments of the GP cannot be
distinguished on conventional imaging.
Image more posterior through the 3rd ventricle shows
components of the basal ganglia: The caudate, putamen, &
GP. Typical pathologic conditions of the basal ganglia
include hypoxic-ischemic insults & toxic-metabolic
processes. Imaging with T1 & T2 as well as DWI
sequences is useful.
Image more posterior shows the basal ganglia & thalamus.
The sulcus terminalis, which separates the caudate head
from the thalamus, contains the thalamostriate vein & stria
terminalis. The stria terminalis is the most important efferent
fiber system of the amygdala & runs below the
thalamostriate vein, but it is not seen on conventional
imaging.
Image more posterior shows the thalamus bordering the 3rd
ventricle. The thalamus contains 3 major nuclear groups
(anterior, medial, & lateral), which are not resolved on
conventional imaging. Other thalamic nuclei include lateral &
medial geniculate nuclei, which may be seen on high-
resolution images. Subthalamic nuclei are located
superolateral to red nucleus & are important in movement
disorders.
Image more posterior shows the caudate body as it
parallels the lateral ventricle. The pulvinar occupies the
posterior 1/3 of the thalamus.
3T AXIAL T2 MR
shows the caudate head as it lies along the floor of the
lateral ventricle. Perivascular spaces, a normal variant, are
seen in a typical location along the lateral aspect of the
anterior commissure. Perivascular spaces follow CSF on all
pulse sequences & have no surrounding gliosis or edema &
no enhancement. Substantia nigra is within the midbrain
cerebral peduncles.
Image through the basal ganglia shows the GP is
hypointense compared with other deep gray nuclei because
of normal age-related iron deposition.
Image more superior through the basal ganglia & thalamus
shows internal capsule components, including the anterior
limb, genu, & posterior limb. The habenula, part of the
epithalamus, transmits olfactory impulses to the brainstem.
The habenula also attaches to the pineal gland.
More superior image shows the basal ganglia & thalamus.
Occasionally, a single large thalamoperforator artery, called
the artery of Percheron or paramedian thalamic artery,
supplies both medial thalami & can result in bilateral medial
thalamic infarcts. This condition may mimic a neoplasm,
such as lymphoma or glioma, on imaging.
This image shows the superior thalamus & superior aspects
of the caudate head & putamen. The anterior limb of the
internal capsule separates the caudate head from the
putamen, while the posterior limb separates the thalamus
from the GP & putamen.
Image at the level of the centrum semiovale shows the
caudate nucleus as it wraps around lateral ventricles.
Huntington disease is characterized by an inability to
prevent unwanted movement. The caudate head becomes
atrophied in this disease, making a boxcar appearance of
the frontal horns of the lateral ventricles.
7T CORONAL T2-TSE MR
First of 6 coronal 2D T2-TSE MR images from anterior to
posterior shows the caudate head continuous with the
inferior putamen immediately above the anterior perforated
substance. Other connections between the caudate &
putamen can be seen along the course of the anterior limb
of the internal capsule.
Image through the anterior commissure shows decreased
signal of the GP relative to the putamen & related to
increased iron deposition in the GP. The putamen is
separated from the GP by the external medullary lamina.
The GP contains 2 segments, lateral & medial, which are
not resolved on conventional imaging.
Image through the anterior limb of the internal capsule is
shown. The insula lies deep in the floor of the sylvian fissure
& is overlapped by the operculum. The insula has many
connections with the thalamus & amygdala as well as with
the olfactory & limbic systems.
Image more posterior through the thalamus shows the
approximate location of the subthalamic nucleus, which is a
biconvex, lens-shaped nucleus medial to the internal capsule
& superolateral to red nucleus. The subthalamic nucleus
plays a major role in the normal function of the basal
ganglia. Pathologically, the subthalamic nucleus is
associated with Parkinson disease & ballism.
Image through the thalamus shows pigmented,
dopaminergic neurons of the substantia nigra. Parkinson
disease is the most common pathologic condition of the
basal ganglia, related to degeneration of dopaminergic
neurons of the substantia nigra & secondary depletion of
dopamine in the putamen & caudate.
Image through the thalamus shows the pulvinar, which
occupies the posterior 1/3 of the thalamus. Pulvinar function
is poorly understood, but it is thought to be an integration
nucleus.
7T POSTMORTEM AXIAL T1 MR
Postmortem high-resolution T1 MR of the basal ganglia at
7T is shown. Images were acquired at 200 micrometer
isotropic resolution.
Postmortem high-resolution T1 MR of the basal ganglia at
7T is shown. At high resolution, mesoscopic properties of
the basal ganglia regions were mapped. For example, wide
axonal bundles of the putamen were seen. Internal &
external segments of the GP were also differentiable.
INPUT AND OUTPUT

Relay nuclei receive defined inputs & project to functionally
distinct areas of the cerebral cortex. Relay nuclei are
involved in primary sensation (VPL, VPM, MGN, & LGN), in
feedback of cerebellar signals (VL), & in feedback of basal
ganglia output (part of VL & VA). Association nuclei receive
most input from & project back to the cerebral cortex in the
association areas. Nonspecific nuclei, including intralaminar
& midline thalamic nuclei, project throughout the cerebral
cortex.
Thalamic nuclei contain inhibitory interneurons (GABAergic
& peptidergic) that modulate signals through the thalamus.
Additionally, neuromodulatory neurotransmitter systems
(such as serotonin & norepinephrine systems) have
terminations within thalamic nuclei.
CONNECTIVITY
The direct pathway starts with cortical input to the striatum.
The striatum inhibits medial GPi. The GPi can inhibit the
thalamus. The indirect pathway starts with cortical input to
the striatum. The striatal neurons inhibit the lateral GP
(GPe). The GPe can inhibit the STN.
Other Deep Gray Nuclei
Main Text
IM AGING ANATOM Y
Overview
• Red nucleus (RN)

Paired, round nuclei in rostral midbrain
Located dorsal and medial to substantia nigra (SN)
T2 hypointense related to high iron content
Responsible for gross motor function via rubrospinal
tract
Part of dentato-rubro-olivary pathway (anatomical
triangle of Guillain-Mollaret)
– Injury may result in hypertrophic olivary
degeneration (HOD) often characterized by palatal
myoclonus
Caudoventral magnocellular part (mcRN) and
rostrodorsal parvocellular part (pcRN); latter represents
majority of nuclear volume
– Afferents from cerebral cortex on their distal
dendrites and from deep cerebellar nuclei on their
proximal dendrites and perikarya
mcRN mainly connected to motor and premotor cortices
(arm and leg areas) and cerebellar interposed nuclei
– Gives rise to crossed rubrospinal tract to spinal
motor neurons and interneurons of distal,
particularly flexor, muscles
– Shows movement-related activity that correlates
with duration, amplitude, and velocity of
independent distal movements
pcRN receives afferents from primary, frontal, and
supplementary motor cortices
– Accounts for 90% of total corticorubral afferents
arising from cortical sublamina V
– Projects onto bulbar olivary complex via central
tegmental tract
– Main efferent is represented by inferior olive
– Receives fibers from parts of cingulate and parietal
cortices
– May be involved in complex motor coordination
rather than simple movements or may even be
involved in nonmotor functions
• Basal forebrain consists of several paleopallial structures,
including substantia innominata, diagonal gyrus, and
paraterminal gyrus
Substantia innominata and diagonal gyrus located in
posterior 1/2 of anterior perforated substance
Paraterminal gyrus is on medial aspect of diagonal gyrus
and posterior to subcallosal area
Nucleus basalis of Meynert (NB)
– Within substantia innominata
– Large cholinergic neurons
– Projections from NB to cerebral cortex
Nucleus of diagonal band of Broca in diagonal gyrus
Medial and lateral septal nuclei in paraterminal gyrus
– Cholinergic projections from nucleus of diagonal
band of Broca and septal nuclei to hippocampal
formation
• Locus coeruleus (LC)
Located adjacent to floor of 4th ventricle in rostral pons
and extends into midbrain to level of inferior colliculi
– LC cells are most densely populated at level of
trochlear nucleus
– Largest group of noradrenergic neurones in central
nervous system
Excitatory projections to
– Majority of cerebral cortex
– Cholinergic neurons of basal forebrain
– Cortically projecting neurons of thalamus
– Serotoninergic neurons of dorsal raphe
– Cholinergic neurons of pedunculopontine and
laterodorsal tegmental nucleus
Inhibitory projections to sleep-promoting GABAergic
neurons of basal forebrain and ventrolateral preoptic
area
Implicated in modulating attentional states
Regulation of arousal and autonomic activity
– Direct projections to spinal cord
– Projections to autonomic nuclei: Dorsal motor
nucleus of vagus, nucleus ambiguus,
rostroventrolateral medulla, Edinger-Westphal
nucleus, caudal raphe, salivatory nuclei,
paraventricular nucleus, amygdala
– LC activation produces increase in sympathetic
activity and decrease in parasympathetic activity via
these projections
• SN : 2 nuclei: Pars compacta (SNPc) and pars reticulata
(SNPr)
Small curvilinear structure located just anterolateral to
RN and medial to cerebral peduncle in midbrain
Extends through midbrain and from pons to subthalamic
region
Pars compacta contains dopaminergic neurons, which
produce dark melanin, appearing black on gross
specimen
– Pars compacta is isointense to gray matter
– Pars compacta is located between pars reticulata and
RN
– Dysfunctional in Parkinson disease (PD) and may
show significant atrophy
Pars reticulata has low signal on T2 and susceptibility-
weighted imaging related to high iron content
Part of A9 dopaminergic (DA) system
– A9 DA fibers vary in size (20-40 µm) and extend
from medial lemniscus to lateral cerebral peduncles
Sensorimotor areas of striatum project to ventrolateral
pallidum and ventrolateral SNPc cell columns
Projections from central striatum terminate more
centrally in both pallidum and ventral densocellular
SNPc
Ventral striatum projects topographically into ventral
pallidum, ventral tegmental area (VTA), and
densocellular SNPc
Pars compacta produce dopamine → increased motor
activity
• VTA
Medial to SN in rostral mesencephalon
~ 60 mm³ in size
Heterogeneous groups of neurons, part of A10 DA
system
– A10 DA fibers within ventromedial midbrain, consist
of small diameter (15-30 µm), nonmyelinated axons
that ascend in medial forebrain bundle
– Synthesizes dopamine, which is sent to nucleus
accumbens (NA)
Reciprocal connections with limbic cortices through
mesolimbic pathway
– Including NA, amygdala, cingulate cortex, and
hippocampal complex
Efferent and afferent associations with prefrontal cortex;
insular cortex; some sensory, motor, and association
areas ( mesocortical pathway ); and with various nuclei
of thalamus and hypothalamus
Reciprocally connected to dorsal raphe nuclei, LC,
various brainstem nuclei, superior colliculus, reticular
formation periaqueductal gray, and spinal cord
VTA receives glutamatergic input from laterodorsal
tegmentum (in mesopontine brainstem) and cholinergic
input from pedunculopontine tegmentum
• Claustrum
Sagittally oriented, curved sheet of subcortical gray
matter between external and extreme capsules
– Lateral to putamen and medial to insular cortex
– Principal cell type: Type 1, large cell whose dendrites
are covered by spines, has reciprocal connections
with ipsilateral and contralateral cerebral cortices
Divided into 3 compartments: Anterior-dorsal connected
with somatosensory and motor cortices, posterior dorsal
(visual cortex), and ventral area (auditory cortex)
Well-marked retinotopically organized map of visual field
and equivalent map of somatosensory field
Ventral claustrum connected to limbic structures, such
as amygdala, subiculum, and cingulate cortex
May synchronize different perceptual, cognitive, and
motor modalities

• DA release can be directly imaged using PET: VTA, SN

• T1WI MR allows identification of LC by exploiting presence
of neuromelanin, pigment produced in noradrenergic
neurons
Increase in T1WI signal intensity
Imaging Pitfalls
• Hypointense area on axial T2WI MR does not completely

overlap with anatomical location of SN
Clinical Importance
• RN
During resting state, participates in cognitive circuits
related to salience and executive control
RN infarction can result in motor symptoms (e.g.,
tremor, asynergia, dysmetria, hypotonia,
adiadochokinesis) and cognitive symptoms (e.g.,
intellectual fatigability, decreased verbal fluency, discrete
memory impairment)
– Motor deficiency could be due to lesion of superior
cerebellar peduncle surrounding RN or lesion of
overlying basal thalamus
Interruption of rubro-olivary tract → myoclonic
movements
• Substantia innominata
Age-related shrinkage of substantia innominata
– Normal aging is accompanied by gradual loss of
cholinergic function caused by dendritic, synaptic,
and axonal degeneration and decrease in trophic
support
– Decrements in gene expression, impairments in
intracellular signaling, and cytoskeletal transport
mediates cholinergic cell atrophy → age-related
functional decline
– Significant degeneration of basal forebrain
cholinergic cells in pathological cognitive deficits,
such as PD, Down syndrome (DS), progressive
supranuclear palsy, Creutzfeldt-Jakob disease,
Korsakoff syndrome, traumatic brain injury
– Atrophy of SN, reflecting degeneration in NB, is
pronounced both in patients with Alzheimer disease
(AD) and in those with non-AD dementia
– Degeneration of cholinergic neurons in NB may have
important contribution to cognitive decline
– Marked neuronal loss of NB in patients with AD
– Diffuse loss of choline acetyltransferase activity in
cerebral cortex related to neuronal depletion of NB
– Pharmacologic intervention along cholinergic and
neurotrophic signaling cascades shown to
ameliorate cholinergic deficit at early stages of
disease and slow progression
• LC
Neuron density within LC decreases with age due to
progressive loss of noradrenergic neurons
Number of LC neurons projecting to frontal cortex and
hippocampus declines with age
– Memory impairment in old age has been related to
loss of LC function
Pathological changes in LC have been noted in number
of neurodegenerative diseases
– PD, AD, Huntington disease, progressive
supranuclear palsy, Lewy body disease, DS, Pick
disease, amyotrophic lateral sclerosis
• Distinct clusters within caudal portion of medial SN/VTA
complex and lateral portion of right SN are predominantly
modulated by anticipation of reward
More rostral part of medial SN/VTA modulated by
novelty
Medial SN/VTA provides integrative information about
novelty and reward or may modulate memory processes
for novel events associated with rewards
– Novel as compared to familiar reward-predictive
stimuli increase functional connectivity of medial
SN/VTA with mesolimbic regions, including NA and
hippocampus, as well as with primary visual cortex
Image Gallery
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DEEP GRAY NUCLEI: 3T T2 MR AND GRAPHIC
Axial T2 MR shows the caudate head as it lies along the
floor of the lateral ventricle. Perivascular spaces, a normal
variant, are seen in a typical location along the lateral
aspect of the anterior commissure. Perivascular spaces
follow CSF on all pulse sequences and have no surrounding
gliosis or edema and no enhancement. The substantia nigra
is within the midbrain, medial to the cerebral peduncle. The
pars reticulata nuclei of the substantia nigra are T2
hypointense related to iron content.
Axial graphics of Parkinson disease (top) and normal brain
(bottom) depict the depigmentation and narrowing of the
substantia nigra, particularly the loss of the pars compacta.
On T2 MR, the hypointense area in the posterior region of
the crus cerebri is the pars reticulata (SNPr). The isointense
area between the SNPr and red nucleus is the pars
compacta of the substantia nigra (SNPc). Narrowing of the
SNPc is a helpful imaging finding in Parkinson disease.
DEEP GRAY NUCLEI: GRAPHIC AND 3T T1 MR

Coronal graphic of the midbrain, pons, and medulla is
sectioned to depict the Guillain-Mollaret triangle. The
triangle of Guillain-Mollaret is composed of the ipsilateral
inferior olivary nucleus (green), dentate nucleus (blue) of the
contralateral cerebellum, and the ipsilateral red nucleus
(red) representing the dentato-rubro-olivary pathway. Injury
of any of these nuclei typically results in hypertrophic olivary
degeneration. Patients with injury to the dentato-rubro-
olivary pathway may present with palatal myoclonus.
Image through the superior pons and cerebellum shows the
approximate location of the medial longitudinal fasciculus
(MLF), just lateral to the midline. The MLF is important in
extraocular muscle movement. Injury to the MLF may be
seen in patients with multiple sclerosis or stroke.
DEEP GRAY NUCLEI: 3T T1 MR

Image at the level of the anterior commissure shows the
anterior limb of the internal capsule as it separates the
caudate head from the putamen and globus pallidus. Globus
pallidus and putamen have different signal intensity related
to increased myelin in globus pallidus. The lateral and
medial segments of globus pallidus cannot be distinguished
on conventional imaging. The nucleus basalis is inferior to
the globus pallidus and within the substantia innominata. It is
located at the subcommissural part of the globus pallidus
and superior and lateral to the hypothalamus.
Axial MP-RAGE image demonstrates the components of the
basal forebrain: The substantia innominata (i), the diagonal
gyrus (d), and the paraterminal gyrus (p). The substantia
innominata and the diagonal gyrus are linearly situated in
the posterior 1/2 of the anterior perforated substance, while
the paraterminal gyrus is located on the medial aspect of
the diagonal gyrus and posterior to the subcallosal area.
DEEP GRAY NUCLEI: BASAL FOREBRAIN

Axial graphic demonstrates components of the basal
forebrain: The substantia innominata (i), the diagonal gyrus
(d), and the paraterminal gyrus (p). The substantia
innominata and the diagonal gyrus are linearly situated in
the posterior 1/2 of the anterior perforated substance,
whereas the paraterminal gyrus is located on the medial
aspect of the diagonal gyrus and posterior to the
subcallosal area(s).
Sagittal MP-RAGE image depicts some of the deep gray
structures of the basal forebrain. Degeneration of the basal
forebrain cholinergic cells is seen in pathological cognitive
deficits, such as Parkinson disease, Down syndrome,
progressive nuclear palsy, Creutzfeldt-Jakob disease, and
traumatic brain injury. Memory impairment in old age has
been related to the loss of locus coeruleus function.
Pathologic changes in the locus coeruleus has also been
noted in a number of neurodegenerative diseases.
Selected References
1. An, H, et al. Quantifying iron deposition within the
substantia nigra of Parkinson’s disease by quantitative
susceptibility mapping. J Neurol Sci. 2018; 386:46–52.
2. Du, G, et al. Distinct progression pattern of susceptibility
MRI in the substantia nigra of Parkinson’s patients. Mov
Disord. 2018; 33(9):1423–1431.
3. Meijer, FJA, et al. Clinical application of brain MRI in the
diagnostic work-up of Parkinsonism. J Parkinsons Dis. 2017;
7(2):211–217.
4. Telford, R, et al. MR anatomy of deep brain nuclei with
special reference to specific diseases and deep brain
stimulation localization. Neuroradiol J. 2014; 27(1):29–43.
5. Krebs, RM, et al. Novelty increases the mesolimbic
functional connectivity of the substantia nigra/ventral
tegmental area (SN/VTA) during reward anticipation:
evidence from high-resolution fMRI. Neuroimage. 2011;
58(2):647–655.
6. Schliebs, R, et al. The cholinergic system in aging and
neuronal degeneration. Behav Brain Res. 2011; 221(2):555–
563.
7. Keren, NI, et al. In vivo mapping of the human locus
coeruleus. Neuroimage. 2009; 47(4):1261–1267.
8. Nioche, C, et al. Functional connectivity of the human red
nucleus in the brain resting state at 3T. AJNR Am J
Neuroradiol. 2009; 30(2):396–403.
9. Samuels, ER, et al. Functional neuroanatomy of the
noradrenergic locus coeruleus: its roles in the regulation of
arousal and autonomic function part I: principles of
functional organisation. Curr Neuropharmacol. 2008;
6(3):235–253.
10. Samuels, ER, et al. Functional neuroanatomy of the
noradrenergic locus coeruleus: its roles in the regulation of
arousal and autonomic function part II: physiological and
pharmacological manipulations and pathological
alterations of locus coeruleus activity in humans. Curr
Neuropharmacol. 2008; 6(3):254–285.
11. Korczyn, AD, et al. Dementia with Lewy bodies. J Neurol Sci.
2006; 248(1-2):3–8.
12. Crick, FC, et al. What is the function of the claustrum?
Philos Trans R Soc Lond B Biol Sci. 2005; 360(1458):1271–
1279.
13. Hanyu, H, et al. MR analysis of the substantia innominata
in normal aging, Alzheimer disease, and other types of
dementia. AJNR Am J Neuroradiol. 2002; 23(1):27–32.
Limbic System
Main Text
T ERM INOLOGY
Definitions
• Limbic lobe
Phylogenetically older cortex
Fewer layers than neocortex
Major role in memory, olfaction, emotion
Composed of subcallosal, cingulate, parahippocampal
gyri + hippocampus, dentate gyrus, subiculum,
entorhinal cortex
• Limbic system
Limbic lobe
Plus some subcortical structures (e.g., amygdala,
mammillary bodies, septal nuclei, etc.)
GROSS ANATOMY
Overview
• Limbic lobe formed by nested C -shaped arches of tissues

surrounding diencephalon, basal ganglia
• Outer arch
Largest of 3 arches
Extends from temporal to frontal lobes and composed of
– Uncus (anterior end of parahippocampal gyrus)
– Parahippocampal gyrus (swings medially at
posterior temporal lobe, becomes isthmus of
cingulate gyrus)
– Cingulate gyrus (anterosuperior continuation of
parahippocampal gyrus)
– Subcallosal (parolfactory area) is anteroinferior
continuation of cingulate gyrus
Curves above callosal sulcus (continuous with
hippocampal sulcus of temporal lobe)
• Middle arch
Extends from temporal to frontal lobes and composed of
– Hippocampus proper (Ammon horn)
– Dentate gyrus
– Supracallosal gyrus [indusium griseum, thin strip of
gray matter that extends from dentate/hippocampus
around corpus callosum (CC) to paraterminal gyrus]
– Paraterminal gyrus (below CC rostrum)
Curves over CC, below callosal sulcus
• Inner arch
Smallest arch
Extends from temporal lobe to mammillary bodies
Composed of fornix, fimbria
IMAGING ANATOMY
Overview
• Hippocampus
Curved structure on medial aspect of temporal lobe that
bulges into floor of temporal horn
Consists of 2 interlocking U -shaped gray matter
structures
– Hippocampus proper (Ammon horn) forms more
superolateral, upside-down U
– Dentate gyrus forms inferomedial U
Has 3 anatomic subdivisions
– Head (pes hippocampus): Most anterior part,
oriented transversely; has 3-4 digitations on superior
surface
– Body: Cylindrical, oriented parasagittally
– Tail: Most posterior portion; narrows then curves
around splenium to form indusium griseum above
CC
• Ammon horn (hippocampus proper)
Subdivided into 4 zones (based on histology of main cell
layers)
– CA1 (Sommer sector): Small pyramidal cells (most
vulnerable; commonly affected by anoxia, mesial
temporal sclerosis)
– CA2: Narrow, dense band of large pyramidal cells
("resistant sector")
– CA3: Wide loose band of large pyramidal cells
– CA4 (end folium): Loosely structured inner zone,
enveloped by dentate gyrus
Blends laterally into subiculum
– Subiculum forms transition to neocortex of
parahippocampal gyrus (entorhinal cortex)
Covered by layer of efferent fibers, alveus
– Alveus borders temporal horn of lateral ventricle
– Forms fimbria → crus of fornix
• Fornix
Primary efferent system from hippocampus
4 parts
– Crura (arch under CC splenium, form part of medial
wall of lateral ventricles)
– Commissure (connects crura)
– Body (formed by convergence of crura, attached to
inferior surface of septum pellucidum)
– Columns (curve inferiorly to mammillary bodies,
anterior thalamus, mammillary bodies, septal nuclei)
• Amygdala
Large complex of gray nuclei medial to uncus, just in
front of temporal horn of lateral ventricle
Tail of caudate nucleus ends in amygdala
Major efferent is stria terminalis
– Stria terminalis arches in sulcus between caudate
nucleus, thalamus
– Forms one margin of choroid fissure (other is fornix)

• MR is best performed in slightly oblique plane,

perpendicular to long axis of hippocampus
Coronal T1 volume images (e.g., MP-RAGE or SPGR): ≤ 1
mm
Coronal T2 high resolution: In-plane resolution ≤ 0.4
mm, slice thickness ≤ 2 mm
Coronal FLAIR whole brain: 1-3 mm
Imaging Pitfalls
• Normal variant is incomplete fusion of hippocampal sulcus

→ CSF-containing "cysts" along medial hippocampus
• In ultrahigh field MR (e.g., 7T MR), field inhomogeneity
could affect signal drop around temporal lobe, affecting
parts of limbic system
Parallel transmit head coil may be used to ameliorate this
problem
Image Gallery
Print Images
GRAPHICS
Sagittal graphic shows 3 arches of the limbic system: The

outer arch (blue) is the parahippocampal gyrus/cingulate
gyrus, the middle arch (yellow) is the hippocampus/indusium
griseum, and the inner arch (purple) is the fimbria/fornix.
The hippocampus lies at the medial temporal lobe and is
largely covered by the parahippocampal gyrus. The
hippocampus extends to the corpus callosum splenium
where it becomes a thin layer of gray matter, the indusium
griseum. The indusium griseum continues along the superior
corpus callosum to end near the anterior commissure.
Fimbria on the dorsal hippocampus continue as fornix, which
arches down to the mammillary body.
Coronal graphic is shown at the level of the anterior 3rd

ventricle and columns of fornix. Cingulum, important
association fibers that lie deep to the cingulate gyrus,
cannot be separated from cingulate gyrus. Indusium
griseum, gray matter that extends along superior corpus
callosum, is also not seen on imaging.
GRAPHIC AND HISTOLOGY

Coronal graphic shows the hippocampus and its surrounding
structures. The hippocampus is a curved structure on the
medial aspect of the temporal lobe. It is composed of 2 U-
shaped gray matter structures, the dentate gyrus (DG) and
the Ammon horn [cornu ammonis (CA)], which are
interlocked. The Ammon horn is further subdivided into 4
parts based on width, cell size, and cell density. The
Ammon horn blends into the subiculum, which borders the
entorhinal cortex (in the anterior part) and parahippocampal
gyrus. White matter tracts extend from the Ammon horn to
form the alveus, which converge to form fimbria.
Coronal histology section of the hippocampus shows
interlocking gray matter of the Ammon horn and the DG.
The Ammon horn is divided into fields CA1, CA2, CA3, and
CA4. CA4 is enveloped by the DG. The alveus contains
efferent fibers from the Ammon horn, which continue along
as fimbria and fornix. The DG consists of a molecular layer,
granular cell layer (GCL), and pyramidal layer.
16.4T POSTMORTEM ULTRAHIGH FIELD MR

Postmortem T1-weighted MR (at 16.4 Tesla) of the
hippocampus shows interlocking gray matter of the Ammon
horn and DG. SRLM of the CA areas extends to the
parasubiculum. DG consists of a molecular layer, GCL, and
pyramidal layer.
Postmortem T1-weighted MR (at 16.4 Tesla) of the
hippocampus of a Braak VI Alzheimer disease patient is
shown. In this case, SRLM of the CA is extremely atrophic.
Hypointense dots that are concentrated in the subiculum,
entorhinal cortex, and parahippocampal gyrus are most
likely microbleeds &/or iron depositions.
3T CORONAL T1 MR
from anterior to posterior is shown. Note the amygdala lies
anterior and superior to the hippocampus at the medial
aspect of the temporal lobe just lateral to the uncus. The tail
of caudate nucleus ends in the amygdala. The pes
hippocampus (hippocampal head) lies just posterior to the
amygdala. The anterior commissure contains crossing fibers
of the temporal cortex, amygdala, and stria terminales.
A more posterior image through the 3rd ventricle shows
digitations of the hippocampal head (pes hippocampus).
The hippocampus is separated from the amygdala by uncal
recess of the temporal horn. The uncus connects the medial
hippocampus with the amygdala.
A more posterior image shows the hippocampal body with
loss of the hippocampal head digitations. The hippocampal
body is bordered medially by the ambient cistern and
laterally by the temporal horn of the lateral ventricle.
A more posterior image through the midthalamus shows the
crura of fornices, which join anteriorly to form the body of
fornix. The body of the hippocampus typically shows the
normal internal architecture of the hippocampus.
Image at the posterior thalamus shows the tail of the
hippocampus. The tail is the narrowest portion of the
hippocampus as it extends posteriorly. The indusium
griseum may be the tiny area of gray matter above the
corpus callosum.
Image through the splenium of the corpus callosum shows
the fimbria as it becomes the crus of fornix. The crus
attaches to the anterior surface of the splenium of the
corpus callosum. At the inferior corpus callosum, the 2 crura
of fornix unite to form the commissure of the fornix
(hippocampal commissure).
7T CORONAL T2 MR
from anterior to posterior is shown. The hippocampal head
(pes hippocampus) is recognized by digitations on its
superior surface. The amygdala is separated from the
hippocampus by the uncal recess of the temporal horn or
the alveus of the hippocampus.
More posterior image shows the body of the hippocampus,
which loses digitations seen in the head. The body of the
fornix arcs over the thalamus to split into 2 anterior columns,
which curve anterior to the foramen of Monro and send
fibers to the mammillary bodies, anterior thalamus, and
septal region.
More posteriorly, the hippocampal body is seen with its
normal architecture. The stratum radiata primarily makes up
white matter between the Ammon horn and the DG. Loss of
this normal architecture is one of the major features of
mesial temporal sclerosis. Other major features are bright
T2 signal and atrophy.
Image shown more posteriorly through the thalamus shows
the crus of the fornix. The hippocampal body is seen with its
normal architecture, bordered laterally by the temporal horn
of the lateral ventricle and medially by the ambient cistern.
In the mesial temporal sclerosis, the hippocampal body is
affected in ~ 90% of patients. Typically, the CA1 and CA4
regions are most affected by mesial temporal sclerosis,
although the entire Ammon horn and DG may be involved.
Image at the posterior thalamus (pulvinar) shows the
transition of the hippocampal body to the hippocampal tail,
the most narrow portion of the hippocampus. In this case,
there are hippocampal fissural cysts bilaterally, which mildly
distort the typical architecture. These cysts are benign and
represent partially unfused hippocampal sulcus.
Image through the splenium of the corpus callosum shows
the fimbria arising from the hippocampus and becoming the
crus of the fornix. The crus attaches to the anterior
splenium. At the inferior corpus callosum, 2 crura of fornix
unite to form the hippocampal commissure (commissure of
fornix).
First of 3 high-resolution coronal T2 MR images through the
anterior aspect of the limbic system is shown. The
amygdala is anterior and superior to the head of the
hippocampus. The amygdala is separated from the
hippocampus by the alveus or uncal recess of the temporal
horn. Note the uncinate gyrus, which connects the medial
hippocampus with the amygdala.
Image at the hippocampal head shows typical digitations at
the superior margin. The mammillary body is well seen
along the inferior 3rd ventricle. The mammillary body may
be atrophied in severe cases of mesial temporal sclerosis
as can the fornix.
Image at the hippocampal body shows normal hippocampal
architecture. The hippocampal sulcus is typically closed in
adult patients as seen here. The parahippocampal gyrus
(entorhinal cortex) continues as the cingulate gyrus under
the splenium of the corpus callosum and above the body of
the corpus callosum as part of the limbic lobe. CA2, CA3,
and CA4 were resolved with high-resolution T2 imaging at 7
Tesla.
3T AXIAL T2 MR
First of 3 axial T2 MR images from inferior to superior at
the level of the cerebral peduncles shows the hippocampus
and amygdala. Note the failure of normal involution of the
hippocampal sulcus resulting in hippocampal fissural cysts
(hippocampal sulcus remnants). These cysts are usually
bilateral and occur between the DG and Ammon horn. This
normal variant occurs in 10-15% of patients.
More superior image shows the hippocampal head and
body. The uncal recess of the temporal horn separates the
amygdala from the hippocampus. The mammillary bodies lie
in the interpeduncular cistern. The uncus forms the lateral
border of the suprasellar cistern.
Image through the superior aspect of the midbrain/inferior
3rd ventricle shows the hypothalamus, fornix, and olfactory
tract. The hippocampal tail is seen curving posteriorly
around the midbrain. The subthalamic nucleus is almond-
shaped and lies anterolateral to the red nucleus.
3T SAGITTAL T1 MR
First of 3 sagittal T1 MR images from lateral to medial
shows the hippocampus and amygdala. Note the thin
temporal horn, which separates the amygdala anteriorly
from the hippocampal head posteriorly.
A more medial image shows commissure of the fornix as it
extends under the body of the corpus callosum. The anterior
commissure is seen in the cross section as it crosses
anterior to columns of the fornix within the anterior 3rd
ventricle. Anterior commissure divides into small anterior
bundle, which connects anterior perforated substance and
olfactory tracts, while the larger posterior bundle connects
the medial temporal gyrus, amygdala, and stria terminalis.
Midline sagittal image shows the body of the fornix, which
divides at the anterior thalamus to become columns of
fornix. The fornix ends in the anterior thalamus, mammillary
body, and septal region. The cingulate gyrus continues
anteriorly to become the subcallosal area.
3T AGING AND ALZHEIMER EXAMPLES

Coronal 3T T2-weighted MR of a cognitively healthy 79-
year-old woman is shown. Normal age-related enlargement
of the ventricle can be seen in both the temporal horn and
the lateral area. Note that the collateral sulcus is also
slightly enlarged with aging.
Coronal 3T T2-weighted MR of an Alzheimer disease
patient (83-year-old woman) is shown. Note the pathologic
enlargement of the lateral ventricle and the shrinkage of the
hippocampus formation. (Courtesy Alzheimer's Disease
Neuroimaging Initiative.)
Sella, Pituitary, and Cavernous Sinus
Main Text
T ERM INOLOGY
Abbreviations
• Adenohypophysis (AH); neurohypophysis (NH)
Synonyms
• Pituitary gland = hypophysis
GROSS ANATOMY
Overview
• Sella turcica (concave midline depression in basisphenoid)

Anterior borders: Tuberculum sellae, anterior clinoid
processes of lesser sphenoid wing
Posterior borders: Dorsum sellae, posterior clinoid
processes
Dural reflections
– Diaphragma sellae forms roof and covers sella
– Variable-sized central opening transmits
infundibulum
– Dura lines floor of hypophyseal fossa
– Laterally, dural reflection forms medial cavernous
sinus (CS) wall
• Hypophysis (pituitary gland)
AH (anterior lobe)
– 80% of gland; wraps anterolaterally around NH
– Includes pars anterior (pars distalis or glandularis),
pars intermedia, pars tuberalis
– Function: Cells secrete somato-, lactogenic, other
hormones
– Vascular supply: Venous (hypophyseal portal
venous via hypothalamus)
Pars intermedia
– < 5% of pituitary, located between AH/NH
– Contains axons from hypothalamus, infundibulum
– Function: Carries releasing hormones to AH, NH
NH (posterior lobe)
– 20% of pituitary
– Includes pars posterior (nervosa), infundibular stem;
inserts into median eminence of hypothalamus
– Contains pituicytes, axons of hypothalamo-
hypophyseal tract
– Function: Stores vasopressin, oxytocin from
hypothalamus
– Vascular supply: Arterial (superior and inferior
hypophyseal arteries)
• CSs
Paired septated, dural-lined venous sinuses, valveless
– Communicate with each other, clival plexus via
intercavernous, basal venous sinuses; posteriorly to
transverse sinuses via superior petrosal sinuses
– Drain inferiorly to pterygoid venous plexi via
emissary veins, to internal jugular vein (IJV) via
inferior petrosal sinuses
– Thicker lateral, thinner medial dural walls enclose
CS, separate it from pituitary
– Posteriorly dural walls enclose Meckel cave
(arachnoid-lined, CSF-filled extension of prepontine
cistern; contains fascicles of CNV, trigeminal
ganglion)
Venous tributaries
– Superior, inferior ophthalmic veins
– Sphenoparietal sinus
Contents [venous blood, cranial nerves, internal carotid
arteries (ICAs) + sympathetic plexus]
– CNIII (oculomotor) lies within superior lateral dural
wall (oculomotor cistern)
– CNIV (trochlear) just below CNIII
– V1 ( ophthalmic division of CNV ) in lateral wall
below CNIV
– V2 ( maxillary division of CNV ) is most inferior
cranial nerve in lateral CS wall
– V3 ( mandibular division of CNV ) does NOT enter
CS proper (passes from Meckel cave inferiorly into
foramen ovale)
– CNVI (abducens) lies within CS proper, next to ICA
IMAGING ANATOMY
Overview
• Hypophysis (pituitary gland)

Gland enhances strongly, uniformly, somewhat < CS
– 15-20% of normal patients have incidental finding of
"filling defects" on T1 C+ MR (cyst, nonfunctioning
microadenoma)
NH usually has short T1 (posterior pituitary "bright
spot") caused by neurosecretory granules (NOT fat!)
• CS (inconstantly visualized at DSA)
Strong, uniform enhancement on CT, T1 C+ MR
Lateral dural walls should be flat or concave
Medial dural walls difficult to image even at 3T

• MR for pituitary, hypothalamic imaging

Coronal/sagittal, 2-3 mm, small FOV
– Precontrast T1-, T2WI
– T1 C+ with fat-saturated helpful in differentiating
postoperative fat packing from enhancing tissue
"Dynamic" scan with rapid bolus of contrast, sequential
scans sorted by slice q. 5-10 secs
Normal Variants
• Normal size, configuration of pituitary varies with age, sex

≤ 6 mm in children; 8 mm in males, postmenopausal
females; physiologic hypertrophy with 10-mm upper
limit in young females (can bulge upwards); 12-14 mm in
pregnant/lactating females
• "Empty" sella
Protrusion of arachnoid, CSF into sella
Normal pituitary becomes flattened, displaced
posteroinferiorly against sellar floor
Rarely symptomatic (may be associated with idiopathic
intracranial hypertension)
Imaging Pitfalls
• Paramedian ICAs ("kissing carotids") can mimic intrasellar

aneurysm, compress pituitary
• Anterior clinoid pneumatization may mimic ICA aneurysms
• Asymmetric skull base marrow (short T1) can mimic
pathology: Fat-saturated MR or CT resolves
• Suprasellar "bright spot" usually ectopic NH, less often
lipoma, etc.
Image Gallery
Print Images
GRAPHICS
Axial graphic of the sella turcica, as viewed from above,

depicts normal sellar and parasellar anatomy. Dura covering
the right cavernous sinus (CS) is removed to show CNV and
CNVI. All cranial nerves are shown in the left CS. The
mandibular division (V3) of CNV does not run through the
CS but exits from Meckel cave inferiorly to enter foramen
ovale. Note the CS is not a single venous channel but is
extensively septated.
Coronal graphic depicts contents of the CSs. The following

cranial nerves traverse the CS within the lateral wall of the
CS, from superior to inferior: Oculomotor (CNIII) within the
oculomotor cistern, trochlear (CNIV), 1st (ophthalmic or V1)
and 2nd (maxillary or V2) divisions of trigeminal (CNV)
nerves. The only cranial nerve actually within the venous
sinusoids of the CS is the abducens nerve (CNVI).
Lateral graphic of normal pituitary is shown. The

adenohypophysis (75-80%) is composed of the pars
tuberalis, pars intermedia, and pars distalis. The
neurohypophysis (20-25%) is composed of the infundibulum
and pars nervosa which inserts into the median eminence of
hypothalamus. The periosteal dural layer covers the sellar
floor.
Lateral graphic demonstrates cranial nerve detail in the
sellar region. CNIII, IV, V1 and V2 are in the lateral dural
wall of the CS. CNVI courses within the venous sinusoids of
the CS, adjacent to the internal carotid artery (not shown).
Meckel cave is a CSF-filled, dural, and arachnoid-lined
invagination that communicates freely with the prepontine
cistern. It contains fascicles of the trigeminal nerve (CNV)
and the trigeminal (gasserian) ganglion.
3T AXIAL T1 C+ MR
Series of 6 axial contrast-enhanced T1 MR images
presented from inferior to superior through skull base and
CS demonstrate right maxillary nerve (V2) passing
anteriorly into foramen rotundum and the left trigeminal
ganglion. The mandibular nerve (V3) will exit inferiorly
through foramen ovale (not shown).
Meckel cave is located posterior, inferior, and lateral
relative to CS. Dura forming posterior part of lateral wall of
CS also forms upper medial 1/3 of Meckel cave, separating
the 2 structures. Note the abducens nerve (CNVI), seen
here as a filling defect within the clival venous plexus, just
before entering Dorello canal.
Both abducens nerves are seen coursing through Dorello
canal to enter the posterior CS. The right trigeminal nerve is
seen entering Meckel cave.
Cranial nerves exiting the CS through the superior orbital
fissure are CNIII, CNIV, CNVI, and the 1st (ophthalmic or
V1) division of CNV.
The optic nerve in the optic canal is located anteromedial to
the anterior clinoid and superomedial to the superior orbital
fissure (SOF). It is separated from the SOF by a thin bony
strut, the "optic strut." The cavernous carotid is
posteromedial to the anterior clinoid. Note origin of the
ophthalmic artery from the internal carotid artery, just above
the transition from intracavernous carotid (below) to
intradural carotid (above) segments.
Pituitary infundibulum is seen within the suprasellar cistern
posterior to the optic chiasm; avid enhancement seen here
is typical. The supraclinoid internal carotid artery (or
terminal segment) is seen laterally.
3T CORONAL T2 MR
First of 6 sequential coronal T2 MR images presented from
posterior to anterior demonstrates the optic tracts within the
posterior aspect of the suprasellar cistern, and anterior
cerebral and supraclinoid internal carotid arteries.
The posterior optic chiasm and part of the pituitary
infundibulum are seen here. Note the internal carotid, middle
cerebral, and anterior cerebral arteries. Individual trigeminal
nerve rootlets are well demonstrated within Meckel cave on
thin-section imaging.
Image at the level of the optic chiasm within the suprasellar
cistern demonstrates normal pituitary gland and regional
vascular anatomy. Note the normal location and appearance
of Meckel cave, seen inferior and lateral. The pituitary gland
and venous blood within the CS are nearly isointense with
each other on T2WI.
Normal appearance of the anterior pituitary gland, CS,
Meckel cave, and suprasellar cistern is seen here. The
oculomotor nerves (CNIII), and optic nerves (CNII) are well
seen. The anterior communicating artery, which connects
the 2 anterior cerebral arteries, and the left middle cerebral
artery genu, are visible here.
The most anterior aspect of the suprasellar cistern
demonstrates normal optic nerves (CNII), oculomotor
nerves (CNIII), cavernous internal carotid arteries, and
anterior cerebral artery within the anterior interhemispheric
fissure.
The anterior clinoid processes seen here form the
anterolateral boundaries of the sella turcica. Note normal
optic nerves, located medial to the anterior clinoids, and the
anterior genu of the cavernous internal carotid artery on the
left.
3T CORONAL T1 C+ MR
First of 6 sequential contrast-enhanced T1 MR images
through the sella, presented from posterior to anterior,
demonstrates detail of Meckel cave. The mandibular (V3)
division of the trigeminal nerve is seen inferior to the
normally enhancing gasserian ganglion.
The pituitary infundibulum insertion into the gland is well
seen here. Note the mandibular nerve (3rd division of
trigeminal nerve, or V3), best seen on the right, as it exits
through foramen ovale, entering the high masticator space.
It is easy to see how extracranial tumors may gain access
to the intracranial compartment without destroying the skull
base, either through direct extension or via perineural
spread.
The left foramen ovale is well seen here. Note the 3rd and
6th cranial nerves within the CS. All of the cranial nerves are
not well seen on this image.
This image demonstrates the oculomotor, abducens, and
maxillary nerves. The pituitary gland enhances less strongly
than venous blood in the CS.
Normal cranial nerves traversing the CS from superior to
inferior include oculomotor nerve, trochlear nerve, abducens
nerve, ophthalmic nerve (V1), and maxillary nerve (V2). The
4th cranial nerve (trochlear) is small and difficult to visualize,
but is normally located in the lateral CS, between the
oculomotor and trigeminal nerves, lateral to the abducens.
The oculomotor nerve is again well seen in the anterior CS,
before it traverses the superior orbital fissure. The vidian
canal, which contains the vidian artery and nerve, is seen in
the sphenoid bone. Note the optic nerves medial to the
anterior clinoids before entering the optic canals.
3T SAGITTAL T2 MR
First of 4 sequential fat-saturated sagittal T2 MR images,
presented midline to lateral, depicts normal sellar osseous
boundaries: Sphenoid and clivus (floor), anterior clinoids
anterolaterally, tuberculum sella anteriorly, dorsum sella and
posterior clinoids posteriorly. The pituitary sits in the sella,
connected superiorly to the hypothalamus via the pituitary
infundibulum. Note the median eminence of hypothalamus,
which forms part of the neurohypophysis.
The tuber cinereum of hypothalamus is located between the
optic chiasm anteriorly and mammillary bodies posteriorly.
Its ventral aspect has small grooves and eminences, but on
imaging it should be smooth, flat, and slightly convex
inferiorly. Thickening or nodularity should raise suspicion for
pathology. The infundibulum courses inferiorly from the
tuber cinereum to the hypophysis.
The optic nerve traverses the suprasellar cistern. Note lack
of sphenoid sinus pneumatization in this case, a normal
anatomical variant that may make transsphenoidal surgery
more difficult.
The optic nerve is seen here entering the posterior aspect
of the optic canal. The suprasellar and interpeduncular
cisterns are normally in communication and are appreciated
here. Volume averaging of the cavernous internal carotid
artery together with part of the pituitary gland on off-midline
images, as seen here, is common and should not be
mistaken for abnormality. The oculomotor nerve courses
anteriorly between the posterior cerebral artery above and
the superior cerebellar artery below.
3T SAGITTAL FAT-SATURATED T1 MR
Unenhanced sagittal T1 fat-saturated MR through the
midline sella turcica demonstrates T1 shortening in the
neurohypophysis (posterior pituitary "bright spot" or PPBS).
The PPBS is related to neurosecretory granules,
vasopressin and oxytocin, not fat, and therefore does not
suppress. Note prominent developmental sphenoid
pneumatization in this case.
Enhanced sagittal T1 fat-saturated MR through the midline
in the same case shows normal pituitary gland and stalk
enhancement. The tuber cinereum and hypothalamus
between the infundibulum and mammillary bodies lacks a
blood-brain barrier and also enhances. Note normal
enhancement of the nasopharyngeal tissue and its proximity
to the central skull base.
Pineal Region
Main Text
T ERM INOLOGY
Synonyms
• Pineal gland, pineal body, epiphysis cerebri

• Posterior commissure: Epithalamic commissure
Definitions
• Epithalamus: Dorsal nuclei of diencephalon
GROSS ANATOMY
Overview
• Major components of pineal region

Pineal gland
Posterior recesses of 3rd ventricle
Internal cerebral veins, vein of Galen; medial posterior
choroidal artery
Epithalamus, quadrigeminal plate (tectum), corpus
callosum
Dura, arachnoid
• Pineal gland
Unpaired midline endocrine organ located within
quadrigeminal cistern, between superior colliculi
Structure
– Attached to diencephalon & posterior wall of 3rd
ventricle by pineal stalk
– Pineal stalk consists of superior/inferior lamina (form
superior & inferior borders of pineal recess of 3rd
ventricle)
– Superior/inferior lamina connect habenular/posterior
commissures, respectively, to pineal gland
– Located under falx cerebri
Vascular supply: Primarily medial posterior choroidal
artery, from P2 branches (lacks blood-brain barrier)
Contents: Pineal parenchymal cells (pinealocytes), some
neuroglial cells (predominately astrocytes)
Functions: Incompletely understood but include
– Secretion of melatonin, thought to regulate
sleep/wake cycle in humans
– Regulation of reproductive function, such as onset
of puberty in humans
• Pineal gland connections
Habenular commissure: Connects habenular,
amygdaloid nuclei, & hippocampi
Posterior commissure: Connections with dorsal
thalamus, superior colliculi, pretectal nuclei, & others;
medial longitudinal fasciculus fibers also cross here
Stria medullaris thalami: Fibers connecting both
habenular nuclei
Habenular nuclei: Relay station for olfactory centers,
brainstem, & pineal
Paraventricular nuclei: Connections with hypothalamus,
hippocampus, amygdala, brainstem, septal nuclei, &
stria terminalis
Superior cervical ganglia sympathetic fibers
Dorsal tegmentum nonadrenergic tract
• Pineal gland boundaries

Superior : Cistern of velum interpositum & internal
cerebral veins
Inferior : Superior colliculi of midbrain tectum
Anterior : Pineal & suprapineal recesses, 3rd ventricle
Posterior and superior : Vein of Galen
Posterior and inferior : Superior cerebellar cistern
IMAGING ANATOMY
Overview
• Pineal gland lacks blood-brain barrier, enhances after

contrast administration
• CT
Pineal gland calcifications common, increase with age
– Globular or concentric lamellar patterns common
– Incidence increases with age (< 3% at 1 year, 7% by
10 years, 33% by 18 years, > 50% of older patients)
– Central calcifications normal, generally ≤ 10 mm
– Larger, peripheral or "exploded" calcifications
abnormal, may signify underlying neoplasm
Habenular commissure sometimes calcifies (C-shaped on
lateral projections)
• MR
Homogeneous enhancement is typical
Incidental, nonneoplastic intrapineal cysts common
– Usually proteinaceous (FLAIR bright)
– Enhancement can be nodular, crescentic, or ring-like

• MR: Thin-section enhanced sagittal images (1 mm) & smaller
field of view (16 cm) best
• Thin-section T2 images, including FIESTA, CISS, etc. often
helpful in differentiating pineal origin mass from tectal mass
Imaging Pitfalls
• Benign, nonneoplastic pineal cysts are common

Most appropriate management & follow-up
recommendations are controversial
Unilocular small simple cysts most common (on routine
imaging), usually do not require follow-up
Suggested follow-up if > 1 cm, hemorrhage, or atypical
enhancement pattern; some authors suggest follow-up
based on clinical indications
Large cysts can become symptomatic (cause
hydrocephalus or Parinaud syndrome)
• Pineal cysts may mimic tumors (pineocytoma) & vice versa
• Exophytic midbrain tectal masses may mimic primary pineal
region tumors (pineal tumors usually compress tectum &
displace it inferiorly)
Clinical Implications
• Parinaud syndrome
Dorsal midbrain or collicular syndrome caused by mass
in pineal region compressing tectal plate
Loss of vertical gaze; nystagmus on attempted
convergence; pseudo-Argyll-Robertson pupil
Classic presentation in patients with pineal tumors (germ
cell tumors & pineal parenchymal tumors)
• Pineal apoplexy
Sudden onset of severe headache, visual problems
Hemorrhage into pineal cyst or pineal neoplasm
Image Gallery
Print Images
GRAPHICS
Midline graphic demonstrates details of the pineal region.

The pineal gland is viewed from above with the corpus
callosum and fornices removed. The internal cerebral veins
extend posteriorly from the foramen of Monro, traversing
the cistern of velum interpositum just superior to the pineal,
and unite posteriorly to form the vein of Galen.
Sagittal midline graphic demonstrates normal anatomy of
the pineal region. The pineal stalk has 2 lamina; these
attach the pineal gland superiorly to the habenular
commissure, with connections to the amygdala and
hippocampus. The inferior lamina attaches the pineal gland
to the posterior commissure, allowing communication with
numerous nuclei of the thalamus, superior colliculi, and
tectal and habenular nuclei, and also contains crossing
fibers of the medial longitudinal fasciculus. The medial
posterior choroidal artery from the posterior cerebral artery,
P2 segment, provides the main vascular supply to the pineal
gland.
3T CORONAL T2 MR
First of 4 coronal T2 MR images, presented sequentially

from posterior to anterior, is seen at the level of the
superior and inferior colliculi and posterior pineal gland.
Image through the body of the pineal gland demonstrates
multiple small cysts within the gland, a common finding on
high-resolution scans. The pineal gland is located just above
the superior colliculi of the midbrain tectum. Exophytic tectal
masses can be difficult to distinguish from pineal origin
masses because of this proximity; thin-slice sagittal &/or
coronal imaging best evaluates this area in this situation.
The suprapineal recess of the 3rd ventricle is seen here as
a small fluid-filled space located between the pineal gland
inferiorly and internal cerebral veins superiorly. The internal
cerebral veins traverse the cistern of the velum
interpositum.
3T SAGITTAL T2 MR
A series of 3 sagittal T2 MR images are presented from
medial to lateral. The midline section through the pineal
gland demonstrates multiple small cysts, commonly seen
with high-resolution imaging. Note the habenular and
posterior commissures, which are connected to the pineal
gland by the superior and inferior lamina, respectively. The
posterior recesses of the 3rd ventricle are well seen here:
The suprapineal recess just above the pineal gland, and the
pineal recess immediately anterior to the gland.
Note the normal pineal location just superior to the tectum.
The inferior lamina is seen here, connecting the pineal gland
and posterior commissure. Internal cerebral veins drain into
the posteriorly located vein of Galen.
The lateral aspect of the pineal gland is demonstrated here.
Note the superior and inferior colliculi of the midbrain
tectum.
Primary Somatosensory Cortex (Areas
1, 2, 3)
Main Text
Location and Boundaries
Location
• Postcentral gyrus
• Posterior wall of central sulcus
• Anterior wall of postcentral sulcus
Boundaries
• Rostral: Fundus of central sulcus

• Caudal: Fundus of postcentral sulcus
• Lateral and ventral: Slightly superior to parietal operculum
and lateral sulcus
• Medial and dorsal: Paracentral lobule
• Surrounded by primary motor cortex (area 4), secondary
somatosensory cortex (area 43), supramarginal gyrus (area
40), and superior parietal cortex (areas 5 and 7)
Function
Somatosensation
• Fine touch
• Texture
• Size and shape
• Proprioception (perception of body movement or position)
• Vibration
• Nociception (pain perception)
• Thermoception
• Sensory homunculus is somatotopic map of body
represented in areas 1, 2, and 3
• Contralateral perception of stimulus
e.g., touch to left side of body results in activity in left
primary somatosensory cortex and vice versa for touch
to right side of body
Structural Connections
Cortical Connections
• Secondary somatosensory cortex (area 43)

• Superior parietal (areas 5 and 7)
• Primary motor cortex (area 4)
Subcortical Connections
• Ventral posterolateral nucleus of thalamus brings sensory

information from body and limbs
• Ventral posteromedial nucleus of thalamus brings sensory
information from head and neck
• Basal ganglia
Functional Connections
Coactive Regions

• Premotor cortex (area 6)
• Supplementary motor area (area 6)
• Superior parietal lobule (areas 5, 7)
• Anterior cingulate cortex (areas 24, 32, 33)
• Thalamus
• Cerebellum
Associated Literature Keywords (NeuroSynth)
• Sensorimotor, motor, finger, hand, somatosensory, tactile,

movements, tapping, practice, muscles
Areas 1-, 2-, 3-Associated Conditions

Sensory Loss, Dysesthesia, Paresthesias
• Can occur anywhere along sensorimotor homunculus

depending on site of cortical injury
Phantom Limb Syndrome
• Abnormal, dysphoric sensation following limb amputation
Image Gallery
Print Images
SOMATOSENSORY C ORTEX: LOC ATION AND
COACTIVATION
Coronal and axial slices from a cytoarchitectonic map of the
somatosensory cortex are shown. This quantitative
probabilistic map was derived from postmortem human
brains and is specific to cellular properties unique to areas
1, 2, and 3 (data source: SPM Anatomy toolbox).
Coactivation map of sensorimotor cortex shows brain
regions that reliably activate in published studies with high
loading of the term "somatosensory" in over 4,000 studies
from the NeuroSynth database.
SOMATOSENSORY CORTEX: CONNECTIVITY

Functional connectivity MR images are shown, averaged
from 1,016 typically developing volunteers (ages 18-30)
from the 1,000 Functional Connectomes and ADHD-200
datasets. The image shows correlation to seed regions in
bilateral Brodmann areas 1, 2, and 3, as defined by the
WFU PickAtlas toolbox for MATLAB. Image was created
using BrainNet Viewer software.
Functional connectivity MR was averaged from 1,003
typically developing volunteers from the Human Connectome
Project dataset. Surface renderings show correlation to a
seed region in the left Brodmann area 3 as defined by the
WFU PickAtlas toolbox for MATLAB. This image was
displayed using BrainNet Viewer software.
Project dataset. Slices show correlation to a seed region in
the bilateral Brodmann area 2 as defined by the WFU
PickAtlas toolbox for MATLAB.
Project dataset. Cerebellar surface rendering shows
correlation to a seed region in the bilateral Brodmann area
1 as defined by the WFU PickAtlas toolbox for MATLAB.
This image was displayed using BrainNet Viewer software.
LOCATION OF BRODMANN AREAS 1, 2, AND 3

Lateral surface-rendered map of the somatosensory cortex
is shaded for areas 1 (pink) and 2 (dark pink) (data source:
Connectome Workbench).
Dorsal surface-rendered map of the somatosensory cortex
is shaded for areas 1 (pink), 2 (dark pink), and 3 (light pink)
(data source: Connectome Workbench).
Medial surface-rendered map of the somatosensory cortex
is shaded for areas 1 (pink) and 2 (dark pink) (data source:
SOMATOSENSORY CORTEX: LOCATION

Medial surface rendering of a cytoarchitectonic map of the
primary somatosensory cortex shows a quantitative
probabilistic map derived from postmortem human brains
and is specific to cellular properties unique to areas 1, 2,
and 3 (data source: JuBrain Cytoarchitectonic Atlas
Viewer).
Lateral surface rendering of the cytoarchitectonic map of
the primary somatosensory cortex is shown.
Dorsal surface rendering of a cytoarchitectonic map of the
primary somatosensory cortex is shown.
Additional Images
Project dataset. Lateral surface rendering shows correlation
to a seed region in the left Brodmann area 3 as defined by
the WFU PickAtlas toolbox for MATLAB. This image was
to a seed region in the right Brodmann area 3 as defined by
Project dataset. Medial surface rendering shows correlation
seed region in the right Brodmann area 3 as defined by the
the left Brodmann area 3 as defined by the WFU PickAtlas
toolbox for MATLAB.
the right Brodmann area 3 as defined by the WFU PickAtlas
toolbox for MATLAB.
Project dataset. Superior surface rendering shows
correlation to a seed region in the left Brodmann area 3 as
defined by the WFU PickAtlas toolbox for MATLAB. This
image was displayed using BrainNet Viewer software.
correlation to a seed region in the right Brodmann area 3 as
toolbox for MATLAB.
toolbox for MATLAB.
toolbox for MATLAB.
toolbox for MATLAB.
Axial slices show functional connectivity MRI, averaged from
1,016 typically developing volunteers (ages 18-30) from the
1,000 Functional Connectomes and ADHD-200 datasets.
The image shows correlation to a seed region in bilateral
Brodmann area 1, as defined by the WFU PickAtlas toolbox
for MATLAB.
1,016 typically developing volunteers (18-30) from the 1,000
Functional Connectomes and ADHD-200 datasets. The
image shows correlation to a seed region in bilateral
for MATLAB.
1,016 typically developing volunteers (18-30) from the 1,000
for MATLAB.
Selected References
1. Gallo, S, et al. The causal role of the somatosensory cortex
in prosocial behaviour. Elife. 7, 2018.
2. Legon, W, et al. Transcranial focused ultrasound modulates
the activity of primary somatosensory cortex in humans.
Nat Neurosci. 2014; 17(2):322–329.
3. Martuzzi, R, et al. Human finger somatotopy in areas 3b, 1,
and 2: a 7T fMRI study using a natural stimulus. Hum Brain
Mapp. 2014; 35(1):213–226.
4. Sánchez-Panchuelo, RM, et al. Regional structural
differences across functionally parcellated Brodmann areas
of human primary somatosensory cortex. Neuroimage. 2014;
93(Pt 2):221–230.
5. Duerden, EG, et al. Localization of pain-related brain
activation: a meta-analysis of neuroimaging data. Hum
Brain Mapp. 2013; 34(1):109–149.
6. Kuehn, E, et al. Judging roughness by sight-A 7-tesla fMRI
study on responsivity of the primary somatosensory cortex
during observed touch of self and others. Hum Brain Mapp.
2013; 34(8):1882–1895.
7. Moore, CI, et al. Neocortical correlates of vibrotactile
detection in humans. J Cogn Neurosci. 2013; 25(1):49–61.
8. Vierck, CJ, et al. Role of primary somatosensory cortex in
the coding of pain. Pain. 2013; 154(3):334–344.
9. Bao, R, et al. Within-limb somatotopic organization in
human SI and parietal operculum for the leg: an fMRI
study. Brain Res. 2012; 1445:30–39.
10. Sanchez-Panchuelo, RM, et al. Within-digit functional
parcellation of Brodmann areas of the human primary
somatosensory cortex using functional magnetic resonance
imaging at 7 tesla. J Neurosci. 2012; 32(45):15815–15822.
11. Van Essen, DC, et al. Parcellations and hemispheric
asymmetries of human cerebral cortex analyzed on surface-
based atlases. Cereb Cortex. 2012; 22(10):2241–2262.
12. Juenger, H, et al. Early determination of somatosensory
cortex in the human brain. Cereb Cortex. 2011; 21(8):1827–
1831.
13. Langner, R, et al. Modality-specific perceptual expectations
selectively modulate baseline activity in auditory,
somatosensory, and visual cortices. Cereb Cortex. 2011;
21(12):2850–2862.
14. Marcus, DS, et al. Informatics and data mining tools and
strategies for the human connectome project. Front
Neuroinform. 2011; 5:4.
15. Schweisfurth, MA, et al. Functional MRI indicates
consistent intra-digit topographic maps in the little but not
the index finger within the human primary somatosensory
cortex. Neuroimage. 2011; 56(4):2138–2143.
16. Simões-Franklin, C, et al. Active and passive touch
differentially activate somatosensory cortex in texture
perception. Hum Brain Mapp. 2011; 32(7):1067–1080.
17. Stringer, EA, et al. Differentiation of somatosensory cortices
by high-resolution fMRI at 7 T. Neuroimage. 2011;
54(2):1012–1020.
18. Serino, A, et al. Touch and the body. Neurosci Biobehav Rev.
2010; 34(2):224–236.
19. Simonyan, K, et al. Abnormal activation of the primary
somatosensory cortex in spasmodic dysphonia: an fMRI
study. Cereb Cortex. 2010; 20(11):2749–2759.
20. Roy, A, et al. Synchrony: a neural correlate of
somatosensory attention. J Neurophysiol. 2007; 98(3):1645–
1661.
21. Blankenburg, F, et al. Evidence for a rostral-to-caudal
somatotopic organization in human primary
somatosensory cortex with mirror-reversal in areas 3b and
1. Cereb Cortex. 2003; 13(9):987–993.
22. Grefkes, C, et al. Human somatosensory area 2: observer-
independent cytoarchitectonic mapping, interindividual
variability, and population map. Neuroimage. 2001;
14(3):617–631.
23. Geyer, S, et al. Areas 3a, 3b, and 1 of human primary
somatosensory cortex. Neuroimage. 1999; 10(1):63–83.
Primary Motor Cortex (Area 4)
Main Text
Location
• Anterior surface of central sulcus and superior portion of

precentral gyrus
Boundaries
• Caudal: Central sulcus

• Rostral: Precentral gyrus
• Medial: Cingulate sulcus
• Lateral: Lateral sulcus
• Surrounded by primary somatosensory cortex (areas 1, 2,
and 3), premotor cortex and supplementary motor area
(area 6), superior parietal cortex (area 5), posterior cingulate
cortex (area 31), and parainsular area (area 43)
Function
Movement
• Initiate voluntary body movements

• Contralateral control of movement
For example, activity in left primary motor cortex results
in right-sided body movement and vice versa
• Motor homunculus
Somatotopic map of body represented in area 4
Body part maps overlap considerably
Body parts may be represented in > 1 region
Imagery and Observation
• Participates in imagining and observing movements

(although conflicting reports)
Input
• Primary somatosensory cortex (areas 1, 2, and 3)

Provides sensory input as feedback for motor output
• Secondary somatosensory cortex (areas 5, 7)
Combines multimodal sensory information to inform
motor output
• Premotor and supplementary motor areas (area 6)
Plan motor output
Execute complex motor tasks
• Cerebellum and basal ganglia (via thalamus)
Involved in motor learning and coordination
Output
• Corticospinal tract
Decussates at pyramids in medulla, which accounts for
contralateral control of body muscles
Innervates alpha motor neurons and interneurons in
spinal cord
1st tract in circuit that controls body muscles
• Corticobulbar tract
Innervates nuclei associated with cranial nerves
1st tract in circuit that controls face, mouth, and throat
muscles
• Corticopontine tract
Innervates pontine nuclei
1st tract in circuit to cerebellum
Coactive Regions

• Cerebellum
• Thalamus
• Lentiform nucleus
• Crus cerebri
Area 4-Associated Disorders

Disorders
• Upper motor neuron syndrome

Injury (e.g., stroke or traumatic brain injury) to
pyramidal neurons in primary motor cortex or
corresponding axons that project to spinal cord
Acute symptoms
– Lack of muscle tone
– Lack of reflexes
Chronic symptoms
– Spasticity
– Poor fine motor ability
– Hyporeflexia
Amyotrophic lateral sclerosis
Phantom limb pain
Parkinson disease
ADHD
Treatment and Recovery
• Electrical stimulation
• Physical therapy and strength training
• Pharmaceuticals
• Somatotopic maps are plastic and can adapt after injury
Image Gallery
Print Images
PRIMARY MOTOR C ORTEX: LOC ATION AND
COACTIVATION
Coronal and axial slices from a cytoarchitectonic map of
primary motor cortex are shown. This quantitative
brains and is specific to cellular properties unique to area 4
(data source: SPM Anatomy toolbox).
Coactivation map of the motor hand area shows that brain
regions reliably activate with the hand motor function (seed
region: x = -24, y = -32, z = 60) in over 4,000 studies from
the NeuroSynth database.
CONNECTIVITY TO RIGHT PRIMARY MOTOR CORTEX

Correlation to a seed region in the right Brodmann area 4,
lateral view is shown.
Correlation to a seed region in the right Brodmann area 4,
medial view is shown.
CONNECTIVITY TO PRIMARY MOTOR CORTEX

Cerebellar surface rendering shows correlation to a seed
region in the bilateral Brodmann area 4.
PRIMARY MOTOR CORTEX: LOCATION

Lateral surface rendering of cytoarchitectonic map for
primary motor cortex (area 4) is shown. This quantitative
probabilistic map is derived from 5 postmortem human
brains and is specific to cellular properties unique to area 4
(data source: JuBrain Cytoarchitectonic Atlas Viewer).
Medial surface rendering of cytoarchitectonic map for
primary motor cortex (area 4) is shown.
Dorsal surface rendering of cytoarchitectonic map for
primary motor cortex (area 4) is shown.
Additional Images
Probabilistic atlas of primary motor cortex is shown (data
source: JuBrain Cytoarchitectonic Atlas Viewer).
toolbox for MATLAB.
toolbox for MATLAB.
Medial surface-rendered view, averaged from the same
data, shows functional connectivity to Brodmann area 4.
Image was created using BrainNet Viewer software.
Ventral surface-rendered view with cerebellum removed,
averaged from the same dataset, shows functional
connectivity to Brodmann area 4. Image was created using
BrainNet Viewer software.
Caudal surface-rendered view, averaged from the same
dataset, shows functional connectivity to Brodmann area 4.
typically developing volunteers (ages 18-30) from 1,000
Functional Connectomes and ADHD-200 datasets. Left
lateral surface rendering shows correlation to a seed region
in bilateral Brodmann area 4, as defined by WFU PickAtlas
toolbox for MATLAB. Image created using BrainNet Viewer
software.
Right lateral surface rendering, averaged from the same
data, shows functional connectivity to Brodmann area 4
(precentral gyrus). Image created using BrainNet Viewer
software.
Dorsal surface-rendered view, averaged from the same
This single slice above the dorsal margin of the lateral
ventricles shows functional connectivity to Brodmann area 4,
including motor cortex and supplementary motor area.
A single axial slice shows functional connectivity MR,
averaged from 1,016 typically developing volunteers (ages
18-30) from the 1,000 Functional Connectomes and ADHD-
200 datasets. The image shows correlation to a seed
region in bilateral Brodmann area 4, as defined by the WFU
A single slice at the level of the ventral lateral nuclei of the
thalamus shows functional connectivity MRI to Brodmann
area 4.
Selected References
1. Svoboda, K, et al. Neural mechanisms of movement
planning: motor cortex and beyond. Curr Opin Neurobiol.
2018; 49:33–41.
2. Kawai, R, et al. Motor cortex is required for learning but not
for executing a motor skill. Neuron. 2015; 86(3):800–812.
3. Li, N, et al. A motor cortex circuit for motor planning and
movement. Nature. 2015; 519(7541):51–56.
4. Hétu, S, et al. The neural network of motor imagery: an
ALE meta-analysis. Neurosci Biobehav Rev. 2013; 37(5):930–
949.
5. Szameitat, AJ, et al. Cortical activation during executed,
imagined, observed, and passive wrist movements in
healthy volunteers and stroke patients. Neuroimage. 2012;
62(1):266–280.
6. Baudrexel, S, et al. Resting state fMRI reveals increased
subthalamic nucleus-motor cortex connectivity in
Parkinson’s disease. Neuroimage. 2011; 55(4):1728–1738.
7. Galea, JM, et al. Dissociating the roles of the cerebellum
and motor cortex during adaptive learning: the motor
cortex retains what the cerebellum learns. Cereb Cortex.
2011; 21(8):1761–1770.
8. Rehme, AK, et al. The role of the contralesional motor
cortex for motor recovery in the early days after stroke
assessed with longitudinal FMRI. Cereb Cortex. 2011;
21(4):756–768.
9. Diers, M, et al. Mirrored, imagined and executed
movements differentially activate sensorimotor cortex in
amputees with and without phantom limb pain. Pain. 2010;
149(2):296–304.
10. Lindenberg, R, et al. Bihemispheric brain stimulation
facilitates motor recovery in chronic stroke patients.
Neurology. 2010; 75(24):2176–2184.
11. Enzinger, C, et al. Brain activity changes associated with
treadmill training after stroke. Stroke. 2009; 40(7):2460–2467.
12. Raposo, A, et al. Modulation of motor and premotor
cortices by actions, action words and action sentences.
Neuropsychologia. 2009; 47(2):388–396.
13. Meier, JD, et al. Complex organization of human primary
motor cortex: a high-resolution fMRI study. J Neurophysiol.
2008; 100(4):1800–1812.
14. Newton, JM, et al. Reliable assessment of lower limb motor
representations with fMRI: use of a novel MR compatible
device for real-time monitoring of ankle, knee and hip
torques. Neuroimage. 2008; 43(1):136–146.
15. Graziano, MS, et al. Mapping behavioral repertoire onto the
cortex. Neuron. 2007; 56(2):239–251.
16. Lotze, M, et al. Neuroimaging patterns associated with
motor control in traumatic brain injury. Neurorehabil Neural
Repair. 2006; 20(1):14–23.
17. Mostofsky, SH, et al. Atypical motor and sensory cortex
activation in attention-deficit/hyperactivity disorder: a
functional magnetic resonance imaging study of simple
sequential finger tapping. Biol Psychiatry. 2006; 59(1):48–56.
18. Geyer, S, et al. Two different areas within the primary motor
cortex of man. Nature. 1996; 382(6594):805–807.
Superior Parietal Cortex (Areas 5, 7)
Main Text
Location
• Medial wall of intraparietal sulcus

• Superior parietal lobule
• Precuneus
• Posterior portion of paracentral lobule
Boundaries
• Lateral and rostral: Postcentral sulcus

• Lateral: Intraparietal sulcus
• Medial and rostral: Imaginary line extending inferior to
central sulcus on medial surface
• Medial and ventral: Subparietal sulcus
• Medial and caudal: Parietooccipital sulcus
• Surrounded by posterior cingulate cortex (area 31), primary
motor cortex (area 4), primary somatosensory cortex (area
2), inferior parietal lobule (areas 39 and 40), and visual
cortex (area 19)
Function
Complex or Higher Order Visual Information
• Processing of numerical information
• Attending to visual stimuli and shifting attention
• Object identification (i.e., item details or features)
Multisensory Attention and Motor Planning
• Contains attentional map with subregions for different

sensory modalities
• Integrates sensory information for motor planning
Memory
• Retaining visual stimuli in working memory; specifically,

location of object
• Retrieving episodic memories
• Distinguishing between familiar and novel items
Cortical
• Inferior parietal lobule (areas 39, 40)

• Superior temporal gyrus and sulcus (area 22)
• Superior prefrontal cortex (area 8)
• Anterior cingulate cortex (areas 24, 32, and 33)
• Posterior cingulate cortex (areas 23, 31)
• Visual cortex (areas 17, 18, and 19)
Subcortical
• Multiple nuclei of thalamus

• Striatum
Coactive Regions
• Inferior parietal lobule (areas 39 and 40)

• Frontal eye fields (area 6)
• Dorsolateral prefrontal cortex (areas 9, 46)
• Insula (area 13)
• Superior temporal gyrus (area 22)
• Middle temporal gyrus (area 21)
• Fusiform gyrus (area 37)
• Parahippocampal gyrus (areas 28, 34, 35, and 36)
• Thalamus
• Cerebellum
• Lentiform nucleus
• Visuomotor, saccade, switch, hands, spatial, eye, reaching,

cue, target, attention
Areas 5- and 7-Associated Disorders

Dyslexia
• Visual attention disorder involving superior parietal lobule

has been hypothesized as pathophysiology of reading
deficits
Image Gallery
Print Images
SUPERIOR PARIETAL C ORTEX: LOC ATION AND
COACTIVATION
Coronal and sagittal slices from a cytoarchitectonic map of

somatosensory association cortex are shown. This
quantitative probabilistic map was derived from postmortem
human brains and is specific to cellular properties unique to
areas 5 and 7 (data source: SPM Anatomy toolbox).
Coactivation map of Brodmann areas 5 and 7 shows brain
regions that reliably activate with the centroid of voxels lying
within areas 5 and 7 in over 4,000 studies from the
NeuroSynth database. This image is the average of left and
right coactivation maps.
CONNECTIVITY TO BRODMANN AREA 5

Functional connectivity MR images were averaged from
This image shows correlation to a seed region in bilateral
for MATLAB, and was created using BrainNet Viewer
software.
CONNECTIVITY TO BRODMANN AREA 7

This image shows correlation to a seed region in bilateral
for MATLAB, and was created using BrainNet Viewer
software.
SUPERIOR PARIETAL CORTEX CONNECTIVITY

the bilateral Brodmann area 7, as defined by the WFU
Surface renderings show correlation to a seed region in the
right Brodmann area 5.
LOCATION OF SUPERIOR PARIETAL CORTEX

Dorsal surface rendering of cytoarchitectonic map of
somatosensory association cortex is shown. This
quantitative probabilistic map is derived from postmortem
human brains and is specific to cellular properties unique to
areas 5 and 7 (data source: JuBrain Cytoarchitectonic Atlas
Viewer).
Lateral surface rendering of cytoarchitectonic map of
somatosensory association cortex is shown.
Medial surface rendering of cytoarchitectonic map of
somatosensory association cortex is shown.
Additional Images
7, as defined by the WFU PickAtlas toolbox for MATLAB.
to a seed region in the left Brodmann area 7, as defined by
to a seed region in the right Brodmann area 7, as defined
by the WFU PickAtlas toolbox for MATLAB. This image was
seed region in the left Brodmann area 7, as defined by the
seed region in the right Brodmann area 7, as defined by the
the left Brodmann area 7, as defined by the WFU PickAtlas
toolbox for MATLAB.
the right Brodmann area 7, as defined by the WFU
correlation to a seed region in the left Brodmann area 7, as
correlation to a seed region in the right Brodmann area 7,
as defined by the WFU PickAtlas toolbox for MATLAB. This
the left Brodmann area 5, as defined by the WFU PickAtlas
toolbox for MATLAB.
correlation to a seed region in the left Brodmann area 5, as
correlation to a seed region in the right Brodmann area 5,
Lateral surface-rendered map of superior parietal cortex is
shaded for areas 5 (peach) and 7 (burnt orange) (data
source: Connectome Workbench).
Medial surface-rendered map of superior parietal cortex is
Dorsal surface-rendered map of superior parietal cortex is
for MATLAB.
Axial slices show functional connectivity MR, averaged from
for MATLAB.
Selected References
1. Caspari, N, et al. Functional similarity of medial superior
parietal areas for shift-selective attention signals in humans
and monkeys. Cereb Cortex. 2018; 28(6):2085–2099.
2. Huk, AC, et al. The role of the lateral intraparietal area in
(the study of) decision making. Annu Rev Neurosci. 2017;
40:349–372.
4. Zhang, S, et al. Functional connectivity mapping of the
human precuneus by resting state fMRI. Neuroimage. 2012;
59(4):3548–3562.
6. Peyrin, C, et al. Superior parietal lobule dysfunction in a
homogeneous group of dyslexic children with a visual
attention span disorder. Brain Lang. 2011; 118(3):128–138.
7. Anderson, JS, et al. Topographic maps of multisensory
attention. Proc Natl Acad Sci U S A. 2010; 107(46):20110–
20114.
8. Blankenburg, F, et al. Studying the role of human parietal
cortex in visuospatial attention with concurrent TMS-fMRI.
Cereb Cortex. 2010; 20(11):2702–2711.
9. Harrison, A, et al. “What” and “where” in the intraparietal
sulcus: an FMRI study of object identity and location in
visual short-term memory. Cereb Cortex. 2010; 20(10):2478–
2485.
10. Nelson, SM, et al. A parcellation scheme for human left
lateral parietal cortex. Neuron. 2010; 67(1):156–170.
11. Santens, S, et al. Number processing pathways in human
parietal cortex. Cereb Cortex. 2010; 20(1):77–88.
12. Sestieri, C, et al. Attention to memory and the environment:
functional specialization and dynamic competition in
human posterior parietal cortex. J Neurosci. 2010;
30(25):8445–8456.
13. Szczepanski, SM, et al. Mechanisms of spatial attention
control in frontal and parietal cortex. J Neurosci. 2010;
30(1):148–160.
14. Vidyasagar, TR, et al. Dyslexia: a deficit in visuo-spatial
attention, not in phonological processing. Trends Cogn Sci.
2010; 14(2):57–63.
15. Margulies, DS, et al. Precuneus shares intrinsic functional
architecture in humans and monkeys. Proc Natl Acad Sci U
S A. 2009; 106(47):20069–20074.
16. Silver, MA, et al. Topographic maps in human frontal and
parietal cortex. Trends Cogn Sci. 2009; 13(11):488–495.
17. Xu, Y. Distinctive neural mechanisms supporting visual
object individuation and identification. J Cogn Neurosci.
2009; 21(3):511–518.
18. Xu, Y, et al. Selecting and perceiving multiple visual objects.
Trends Cogn Sci. 2009; 13(4):167–174.
19. Scheperjans, F, et al. Probabilistic maps, morphometry, and
variability of cytoarchitectonic areas in the human superior
parietal cortex. Cereb Cortex. 2008; 18(9):2141–2157.
20. Scheperjans, F, et al. Observer-independent
cytoarchitectonic mapping of the human superior parietal
cortex. Cereb Cortex. 2008; 18(4):846–867.
21. Choi, HJ, et al. Cytoarchitectonic identification and
probabilistic mapping of two distinct areas within the
anterior ventral bank of the human intraparietal sulcus. J
Comp Neurol. 2006; 495(1):53–69.
22. Tanabe, HC, et al. The sensorimotor transformation of
cross-modal spatial information in the anterior intraparietal
sulcus as revealed by functional MRI. Brain Res Cogn Brain
Res. 2005; 22(3):385–396.
23. Piazza, M, et al. Tuning curves for approximate numerosity
in the human intraparietal sulcus. Neuron. 2004; 44(3):547–
555.
Premotor Cortex and Supplementary
Motor Area (Area 6)
Main Text
Location
• Dorsal premotor cortex

Caudal portions of inferior and middle frontal gyri and
inferior frontal sulcus
Includes frontal eye fields at confluence of superior
frontal and precentral sulci
Rostral to hand area of primary motor cortex (area 4)
and caudal to superior prefrontal cortex (area 8)
• Ventral premotor cortex
Caudal portions of middle and lateral superior frontal
gyri and superior frontal sulcus
Rostral to face area of primary motor cortex (area 4) and
caudal to Broca area (in particular area 44)
• Supplementary motor area
Caudal and medial portion of superior frontal gyrus
Rostral to leg area of primary motor cortex (area 4) and
caudal to presupplementary motor area
• Presupplementary motor area
Portion of medial superior frontal gyrus
Rostral to supplementary motor area and caudal to
superior prefrontal cortex (area 8)
Boundaries
• Caudal: Precentral gyrus

• Medial and ventral: Cingulate sulcus
• Lateral and ventral: Lateral sulcus
• Rostral: Ventral portions of inferior (area 44), middle (area
9), and superior frontal (area 8) gyri
• Surrounded by anterior cingulate cortex (areas 24, 32),
posterior cingulate cortex (area 31), primary motor cortex
(area 4), parainsular cortex (area 43), inferior frontal gyrus
(area 44), dorsolateral prefrontal cortex (area 9), and
superior prefrontal cortex (area 8)
Function
Actions
• Supplementary motor area selects actions initiated from

internal cues
• Premotor cortex selects actions initiated from external cues
• Motor planning
• Coordinate action sequence
• Voluntary eye movements
• Acquisition of motor skills
• Timing of action execution
• Motor flexibility
Inhibit action
Change action plan
Initiate new action
Imagery and Observation
• Passively observing or imagining action execution

• Primary sensorimotor cortex (areas 1, 2, and 3)

• Superior parietal cortex (areas 5, 7)
• Supramarginal gyrus (area 40)
• Orbitofrontal cortex (area 11)
• Corticospinal and corticobulbar tracts

Secondary source of corticospinal and corticobulbar
tracts compared to primary motor cortex
Stabilization of trunk muscles
• Thalamus
• Basal ganglia
Coactive Regions
• Primary sensorimotor cortex (areas 1, 2, 3, and 4)

• Intraparietal sulcus (area 5, 7)
• Anterior insula (area 13)
• Thalamus
• Putamen
• Globus pallidus
• Cerebellum
• Saccade, eye, shift, movement, spatial, execution, load,

• Saccade, eye, shift, movement, spatial, execution, load,
position, attention

Disorders
• Supplementary motor area syndrome: Injury to

supplementary motor area, especially if bilateral
• Can produce language (presupplementary motor area) or
self-initiated motor (supplementary motor area) deficits
• Damage to premotor cortex results in difficulty learning to
select or carry out action from visual or verbal cues
Treatment and Recovery
• Symptoms typically improve or resolve over 6 weeks

following acute injury
Image Gallery
Print Images
PREMOTOR CORTEX: LOCATION AND COACTIVATION
Cytoarchitectonic map of the premotor cortex and
supplementary motor area represents a quantitative
and is specific to cellular properties unique to area 6 (data
source: SPM Anatomy toolbox).
Coactivation map of Brodmann area 6 shows brain regions
that reliably activate with the centroid of voxels lying within
area 6 in over 4,000 studies from the NeuroSynth database.
This image is the average of left and right coactivation
maps.
FUNCTIONAL CONNECTIVITY TO PREMOTOR CORTEX

Project dataset. Surface renderings show the correlation to
a seed region in the left Brodmann area 6 as defined by the
Project dataset. Cerebellar surface rendering shows the
Project dataset. Slices show the correlation to a seed
region in the bilateral Brodmann area 6 as defined by the
WFU PickAtlas toolbox for MATLAB.
PREMOTOR CORTEX: LOCATION

Dorsal surface rendering of a cytoarchitectonic map for the
premotor cortex and supplementary motor area is shown.
The image is a quantitative probabilistic map that is derived
from postmortem human brains and specific to cellular
properties unique to area 6 (data source: JuBrain
Cytoarchitectonic Atlas Viewer).
Lateral surface rendering of a cytoarchitectonic map for the
Medial surface rendering of a cytoarchitectonic map for the
Medial surface map of the premotor cortex and
supplementary motor area represents Brodmann cortical
parcellation scheme for area 6 (data source: Connectome
Workbench).
Lateral oblique surface map of the premotor cortex and
supplementary motor area is shown.
Dorsal surface map of the premotor cortex and
supplementary motor area is shown.
Additional Images
Right lateral surface-rendered view shows functional
connectivity to a seed composed of bilateral Brodmann area
6. This image was created in BrainNet Viewer.
Frontal surface-rendered view shows functional connectivity
to a seed composed of bilateral Brodmann area 6. This
image was created in BrainNet Viewer.
Ventral surface-rendered view, with cerebellum removed,
shows functional connectivity to a seed composed of
bilateral Brodmann area 6. Image was created in BrainNet
Viewer.
typically developing volunteers (ages 18-30) from the 1,000
lateral surface-rendered view shows the correlation to a
seed region in bilateral Brodmann area 6 as defined by the
created using BrainNet Viewer software.
Dorsal surface-rendered view shows functional connectivity
MR to Brodmann area 6. This image was created using
Medial surface-rendered view shows functional connectivity
MR to Brodmann area 6. This image was created using
Project dataset. Lateral surface rendering shows the
Project dataset. Medial surface rendering shows the
a seed region in the right Brodmann area 6 as defined by
region in the left Brodmann area 6 as defined by the WFU
region in the right Brodmann area 6 as defined by the WFU
Project dataset. Superior surface rendering shows the
A single axial slice near the vertex shows functional
connectivity MR to Brodmann area 6.
A single axial slice at the dorsal margin of the lateral
ventricles shows functional connectivity MR to Brodmann
area 6.
A single axial slice at the level of the mid thalami shows
functional connectivity MR to Brodmann area 6.
Selected References
1. Genon, S, et al. The heterogeneity of the left dorsal
premotor cortex evidenced by multimodal connectivity-
based parcellation and functional characterization.
Neuroimage. 2018; 170:400–411.
2. Rossi-Pool, R, et al. Decoding a decision process in the
neuronal population of dorsal premotor cortex. Neuron.
2017; 96(6):1432. [46.e7].
3. Hoffstaedter, F, et al. The “what” and “when” of self-
initiated movements. Cereb Cortex. 2013; 23(3):520–530.
4. Hétu, S, et al. The neural network of motor imagery: an
ALE meta-analysis. Neurosci Biobehav Rev. 2013; 37(5):930–
949.
5. Duque, J, et al. Dissociating the role of prefrontal and
premotor cortices in controlling inhibitory mechanisms
during motor preparation. J Neurosci. 2012; 32(3):806–816.
6. Molenberghs, P, et al. Brain regions with mirror properties:
a meta-analysis of 125 human fMRI studies. Neurosci
Biobehav Rev. 2012; 36(1):341–349.
7. Szameitat, AJ, et al. Cortical activation during executed,
imagined, observed, and passive wrist movements in
healthy volunteers and stroke patients. Neuroimage. 2012;
62(1):266–280.
9. Zhang, S, et al. Resting-state functional connectivity of the
medial superior frontal cortex. Cereb Cortex. 2012; 22(1):99–
111.
11. Schilbach, L, et al. Eyes on me: an fMRI study of the effects
of social gaze on action control. Soc Cogn Affect Neurosci.
2011; 6(4):393–403.
12. Shannon, BJ, et al. Premotor functional connectivity
predicts impulsivity in juvenile offenders. Proc Natl Acad Sci
U S A. 2011; 108(27):11241–11245.
13. Stadler, W, et al. Predicting and memorizing observed
action: differential premotor cortex involvement. Hum Brain
Mapp. 2011; 32(5):677–687.
14. Tremblay, P, et al. On the context-dependent nature of the
contribution of the ventral premotor cortex to speech
perception. Neuroimage. 2011; 57(4):1561–1571.
15. Caspers, S, et al. ALE meta-analysis of action observation
and imitation in the human brain. Neuroimage. 2010;
50(3):1148–1167.
16. Lisberger, SG. Visual guidance of smooth-pursuit eye
movements: sensation, action, and what happens in
between. Neuron. 2010; 66(4):477–491.
17. Rizzolatti, G, et al. The functional role of the parieto-frontal
mirror circuit: interpretations and misinterpretations. Nat
Rev Neurosci. 2010; 11(4):264–274.
18. Schubotz, RI, et al. Anatomical and functional parcellation
of the human lateral premotor cortex. Neuroimage. 2010;
50(2):396–408.
19. Desmurget, M, et al. A parietal-premotor network for
movement intention and motor awareness. Trends Cogn Sci.
2009; 13(10):411–419.
20. Iacoboni, M. Imitation, empathy, and mirror neurons. Annu
Rev Psychol. 2009; 60:653–670.
21. Nachev, P, et al. Functional role of the supplementary and
pre-supplementary motor areas. Nat Rev Neurosci. 2008;
9(11):856–869.
22. Geyer, S. The microstructural border between the motor
and the cognitive domain in the human cerebral cortex. Adv
Anat Embryol Cell Biol. 2004; 174:I–VIII. [1-89].
Superior Prefrontal Cortex (Area 8)
Main Text
Location
• Caudal portion of middle frontal gyrus

• Caudal portion of both medial and lateral superior frontal
gyrus
Boundaries
• Medial: Cingulate sulcus

• Lateral: Inferior frontal sulcus
• Rostral: Middle of superior and middle frontal gyri
• Caudal: Caudal end of superior and middle frontal gyri
• Surrounded by anterior cingulate cortex (area 32), premotor
cortex (area 6), presupplementary motor area (area 6), and
dorsolateral prefrontal cortex (area 9)
Function
Theory of Mind
• Mentalizing or inferring mental states of others
Simulating Future Events

• Predicting behavior of others by creating model based on
personality traits
• Imaging and planning future events
Self-Referential Processes
• Autobiographical memory (i.e., recalling past personal

experience)
• Internal dialogue
Cortical

• Inferior frontal gyrus (areas 44, 45, and 47)
• Anterior cingulate cortex (area 32)
• Frontal pole (area 10)
• Retrosplenial cingulate cortex (area 30)
• Parahippocampal gyrus (areas 28, 34, 35, and 36)
• Superior temporal gyrus and sulcus (area 22)
• Insula (area 13)
Subcortical
• Mediodorsal nucleus of thalamus
Coactive Regions
• Frontal pole (area 10)

• Precuneus (area 5)
• Middle temporal gyrus (area 21)
• Default, colors, resting state, reactivity, money, dyslexia,

vision, subsequent, autobiographical, past, associative

Alzheimer Disease
• Amyloid-β deposits in regions of default mode network,

including superior prefrontal cortex
Autism
• Characterized by difficulty empathizing and inferring others'

mental states
Major Depressive Disorder
• Characterized by rumination and focusing on self
Image Gallery
Print Images
SUPERIOR PREFRONTALC ORTEX: LOC ATION AND
COACTIVATION
Axial and sagittal sections of superior prefrontal cortex map
are shown, representing the Brodmann cortical parcellation
scheme for area 8 (data source: WFU PickAtlas).
area 8 in over 4,000 studies from the NeuroSynth database.
Image is the average of left and right coactivation maps.
CONNECTIVITY TO SUPERIOR PREFRONTAL CORTEX

Axial slice at the level of the anterior commissure shows
functional connectivity MR averaged from 1,016 typically
developing volunteers (ages 18-30) from the 1,000
for MATLAB.
Axial slice at the level of the body of the fornix shows
functional connectivity MR to Brodmann area 8.
Axial slice above the dorsal margin of the lateral ventricles
shows functional connectivity MR to Brodmann area 8.
SUPERIOR PREFRONTAL CORTEX LOCATION

Lateral surface map of the frontal eye fields shows
Brodmann cortical parcellation scheme for area 8 (data
Dorsal surface map of the frontal eye fields shows
Brodmann cortical parcellation scheme for area 8.
Medial surface map of the frontal eye fields shows
Brodmann cortical parcellation scheme for area 8.
Additional Images
toolbox for MATLAB.
toolbox for MATLAB.
Medial surface-rendered view shows functional connectivity
MR to Brodmann area 8. Image was created using BrainNet
Viewer software.
Functional Connectomes and ADHD-200 datasets. Image
shows correlation to a seed region in bilateral Brodmann
area 8, as defined by the WFU PickAtlas toolbox for
MATLAB. Left lateral surface-rendered view is seen. Image
was created using BrainNet Viewer software.
Right lateral surface-rendered view shows functional
connectivity MR to Brodmann area 8. Image was created
Dorsal surface-rendered view shows functional connectivity
Viewer software.
Frontal surface-rendered view shows functional connectivity
Viewer software.
Caudal surface-rendered view shows functional connectivity
Viewer software.
Selected References
1. Harrison, BJ, et al. Human ventromedial prefrontal cortex
and the positive affective processing of safety signals.
Neuroimage. 2017; 152:12–18.
2. Wegrzyn, M, et al. Auditory attention enhances processing
of positive and negative words in inferior and superior
prefrontal cortex. Cortex. 2017; 96:31–45.
3. Hassabis, D, et al. Imagine all the people: how the brain
creates and uses personality models to predict behavior.
Cereb Cortex. 2014; 24(8):1979–1987.
4. Laurent, HK, et al. A cry in the dark: depressed mothers
show reduced neural activation to their own infant’s cry.
Soc Cogn Affect Neurosci. 2012; 7(2):125–134.
5. Samson, F, et al. Enhanced visual functioning in autism: an
ALE meta-analysis. Hum Brain Mapp. 2012; 33(7):1553–
1581.
6. Spreng, RN, et al. I remember you: a role for memory in
social cognition and the functional neuroanatomy of their
interaction. Brain Res. 2012; 1428:43–50.
9. Andrews-Hanna, JR, et al. Functional-anatomic
fractionation of the brain’s default network. Neuron. 2010;
65(4):550–562.
10. Spreng, RN, et al. Default network activity, coupled with the
frontoparietal control network, supports goal-directed
cognition. Neuroimage. 2010; 53(1):303–317.
11. Spreng, RN, et al. Patterns of brain activity supporting
autobiographical memory, prospection, and theory of mind,
and their relationship to the default mode network. J Cogn
Neurosci. 2010; 22(6):1112–1123.
12. Buckner, RL, et al. Cortical hubs revealed by intrinsic
functional connectivity: mapping, assessment of stability,
and relation to Alzheimer’s disease. J Neurosci. 2009;
29(6):1860–1873.
13. Spreng, RN, et al. The common neural basis of
autobiographical memory, prospection, navigation, theory
of mind, and the default mode: a quantitative meta-
analysis. J Cogn Neurosci. 2009; 21(3):489–510.
14. Buckner, RL, et al. The brain’s default network: anatomy,
function, and relevance to disease. Ann N Y Acad Sci. 2008;
1124:1–38.
15. Buckner, RL, et al. Self-projection and the brain. Trends
Cogn Sci. 2007; 11(2):49–57.
16. Buckner, RL, et al. Molecular, structural, and functional
characterization of Alzheimer’s disease: evidence for a
relationship between default activity, amyloid, and memory.
J Neurosci. 2005; 25(34):7709–7717.
17. Maldjian, JA, et al. An automated method for
neuroanatomic and cytoarchitectonic atlas-based
interrogation of fMRI data sets. Neuroimage. 2003;
19(3):1233–1239.
Dorsolateral Prefrontal Cortex (Areas
9, 46)
Main Text
Location
• Middle frontal gyrus

• Middle portion (medial and lateral) of superior frontal gyrus
Boundaries
• Rostral: Frontal pole

• Caudal: Caudal portion of middle frontal gyrus
• Lateral and ventral: Inferior frontal sulcus
• Medial and dorsal: Cingulate sulcus
• Surrounded by frontal pole (area 10), inferior frontal gyrus
(areas 44, 45, and 47), premotor cortex (area 6), superior
prefrontal cortex (area 8), and anterior cingulate cortex (area
32)
Function
Memory
• Encoding and retrieval stages of familiar stimuli during

working memory
• Updating items retained during working memory
• Retaining items held in memory in presence of distraction
Planning
• Ordering events appropriately to complete task
Decision Making
• Pattern recognition and comparison

• Analyzing risk in potential decisions

• Mediodorsal nucleus of thalamus

• Basal ganglia
• Hippocampus
• Ventral tegmental area
Coactive Regions
• Superior prefrontal cortex (area 8)

• Anterior insula (area 13)
• Thalamus
• Basal ganglia
• Superior parietal cortex (areas 5, 7)
Intraparietal sulcus
Precuneus
Supramarginal gyrus (area 40)
Angular gyrus (area 39)
• Cingulate cortex (areas 23, 24, 31, 32, and 33)
• Execution, preparation, monitoring, planning, sequence,

imagery, movements, working memory, outcome, counting

Major Depressive Disorder
• Common site of stimulation when treating depression with

repetitive transcranial magnetic stimulation
• Hypoactivity normalized by antidepressant medication
Posttraumatic Stress Disorder
• Hypoactive in patients when anticipating negative

experience
Schizophrenia
• Increased activity predicts better patient response to

cognitive behavioral therapy
• Practice-induced decrease in dorsolateral prefrontal activity
in patients
Addiction
• Dorsolateral prefrontal cortex modulates brain regions

responsible for assigning value to rewarding stimulus in
smokers
Image Gallery
Print Images
C OAC TIVATION OF DORSOLATERAL PREFRONTAL
CORTEX
Axial and sagittal slices show the relative positions of dorsal
prefrontal cortex area 9 and area 46 (data source: WFU
PickAtlas).
Coactivation map of Brodmann areas 9 and 46 shows brain

regions that reliably activate with the centroid of voxels lying
within areas 9 and 46 in > 4,000 studies from the
NeuroSynth database. Image is the average of left and right
coactivation maps.
C ONNEC TIVITY TO DORSOLATERAL PREFRONTAL
CORTEX

datasets. The image shows correlation to a seed region in
bilateral Brodmann area 46, as defined by the WFU
PickAtlas toolbox for MATLAB. Image was created using
Correlation to a seed region in bilateral Brodmann area 9.
Correlation to a seed region in right Brodmann area 46 is
shown.
C ONNEC TIVITY TO BILATERAL DORSOLATERAL

PREFRONTAL CORTEX
BRODMANN AREAS 9 AND 46

Frontal surface-rendered map of areas 9 and 46 is shown,
representing Brodmann cortical parcellation scheme for
areas 9 and 46 (data source: Connectome Workbench).
Lateral surface-rendered map of areas 9 and 46 is shown.
Dorsal surface rendered map of areas 9 and 46 is shown.
Additional Images
Medial surface rendered map of areas 9 and 46 is shown,
areas 9 and 46. (Data source: Connectome Workbench.)
Frontal surface-rendered map of dorsal prefrontal cortex is
shaded in blue, representing Brodmann cortical parcellation
scheme for area 9 (data source: Connectome Workbench).
Lateral surface-rendered map of dorsal prefrontal cortex is
Dorsal surface-rendered map of dorsal prefrontal cortex is
Frontal surface-rendered map of dorsal prefrontal cortex is
shaded in brown, representing Brodmann cortical
Workbench).
Dorsal surface-rendered map of dorsal prefrontal cortex is
Workbench).
Lateral surface-rendered map of dorsal prefrontal cortex is
Workbench).
Brodmann area 46, as defined by the WFU PickAtlas
toolbox for MATLAB.
for MATLAB.
correlation to a seed region in right Brodmann area 9 as
defined by the WFU PickAtlas toolbox for MATLAB. Image
correlation to a seed region in left Brodmann area 9 as
seed region in right Brodmann area 9 as defined by the
toolbox for MATLAB.
toolbox for MATLAB.
correlation to a seed region in bilateral Brodmann area 9 as
to a seed region in right Brodmann area 46 as defined by
the WFU PickAtlas toolbox for MATLAB. Image was
to a seed region in left Brodmann area 46 as defined by the
the right Brodmann area 46 as defined by the WFU
toolbox for MATLAB.
seed region in left Brodmann area 46 as defined by the
to a seed region in right Brodmann area 46 as defined by
the WFU PickAtlas toolbox for MATLAB. Image was
to a seed region in left Brodmann area 46 as defined by the
correlation to a seed region in bilateral Brodmann area 46
as defined by the WFU PickAtlas toolbox for MATLAB.
Selected References
1. Klaus, J, et al. The role of left dorsolateral prefrontal cortex
in language processing. Neuroscience. 2018; 377:197–205.
2. Dedoncker, J, et al. A systematic review and meta-analysis
of the effects of transcranial direct current stimulation
(tDCS) over the dorsolateral prefrontal cortex in healthy
and neuropsychiatric samples: influence of stimulation
parameters. Brain Stimul. 2016; 9(4):501–517.
3. Jarbo, K, et al. Converging structural and functional
connectivity of orbitofrontal, dorsolateral prefrontal, and
posterior parietal cortex in the human striatum. J Neurosci.
2015; 35(9):3865–3878.
4. Brunoni, AR, et al. Working memory improvement with
non-invasive brain stimulation of the dorsolateral prefrontal
cortex: a systematic review and meta-analysis. Brain Cogn.
2014; 86:1–9.
5. Blumenfeld, RS, et al. Lateral prefrontal cortex is organized
into parallel dorsal and ventral streams along the rostro-
caudal axis. Cereb Cortex. 2013; 23(10):2457–2466.
6. Galván, A, et al. Greater risk sensitivity of dorsolateral
prefrontal cortex in young smokers than in nonsmokers.
Psychopharmacology (Berl). 2013; 229(2):345–355.
7. Hayashi, T, et al. Dorsolateral prefrontal and orbitofrontal
cortex interactions during self-control of cigarette craving.
Proc Natl Acad Sci U S A. 2013; 110(11):4422–4427.
8. Schon, K, et al. Complementary roles of medial temporal
lobes and mid-dorsolateral prefrontal cortex for working
memory for novel and familiar trial-unique visual stimuli.
Eur J Neurosci. 2013; 37(4):668–678.
9. Aupperle, RL, et al. Dorsolateral prefrontal cortex
activation during emotional anticipation and
neuropsychological performance in posttraumatic stress
disorder. Arch Gen Psychiatry. 2012; 69(4):360–371.
11. Baumgartner, T, et al. Dorsolateral and ventromedial
prefrontal cortex orchestrate normative choice. Nat
Neurosci. 2011; 14(11):1468–1474.
12. Blumenfeld, RS, et al. Putting the pieces together: the role of
dorsolateral prefrontal cortex in relational memory
encoding. J Cogn Neurosci. 2011; 23(1):257–265.
13. Kaller, CP, et al. Dissociable contributions of left and right
dorsolateral prefrontal cortex in planning. Cereb Cortex.
2011; 21(2):307–317.
15. Staudinger, MR, et al. Dorsolateral prefrontal cortex
modulates striatal reward encoding during reappraisal of
reward anticipation. Cereb Cortex. 2011; 21(11):2578–2588.
16. Park, SQ, et al. Prefrontal cortex fails to learn from reward
prediction errors in alcohol dependence. J Neurosci. 2010;
30(22):7749–7753.
17. van Veelen, NM, et al. Left dorsolateral prefrontal cortex
dysfunction in medication-naive schizophrenia. Schizophr
Res. 2010; 123(1):22–29.
18. Fales, CL, et al. Antidepressant treatment normalizes
hypoactivity in dorsolateral prefrontal cortex during
emotional interference processing in major depression. J
Affect Disord. 2009; 112(1-3):206–211.
19. Hare, TA, et al. Self-control in decision-making involves
modulation of the vmPFC valuation system. Science. 2009;
324(5927):646–648.
20. Koenigs, M, et al. The functional neuroanatomy of
depression: distinct roles for ventromedial and dorsolateral
prefrontal cortex. Behav Brain Res. 2009; 201(2):239–243.
21. Kumari, V, et al. Dorsolateral prefrontal cortex activity
predicts responsiveness to cognitive-behavioral therapy in
schizophrenia. Biol Psychiatry. 2009; 66(6):594–602.
22. Qin, S, et al. Acute psychological stress reduces working
memory-related activity in the dorsolateral prefrontal
cortex. Biol Psychiatry. 2009; 66(1):25–32.
23. Ruge, H, et al. Attention, intention, and strategy in
preparatory control. Neuropsychologia. 2009; 47(7):1670–
1685.
19(3):1233–1239.
Frontal Pole (Area 10)
Main Text
T ERM INOLOGY
Abbreviations
• Frontal pole (Fp)

Location
• Most rostral portion of prefrontal cortex

• Includes frontomarginal sulcus, rostral part of superior
frontal gyrus, and small parts of middle frontal gyrus
Boundaries
• No precise anatomic landmarks are available

Bounded rostrally and laterally by middle frontal area
(area 46) and superior frontal gyrus (area 9)
Bounded caudally by area 32 rostral to cingulate gyrus
Bounded ventrally by area 11 (rostral end of olfactory
sulcus)
• 2 distinct cytoarchitectonic regions are present in area 10
Fp1 extends further laterally and rostrally
Fp2 occupies medial Fp and is more caudal than Fp1
Function
Fp1
• Cognition
• Working memory
• Perception
Fp2
• Affective processing
• Mentalizing
• Social cognition
Frontal Pole Function
• Electrophysiology in macaques suggests monitoring of

action outcomes
• Lesion data
Fp involved in goal-directed behaviors and making future
choices
• Proposed function
Maintenance of goals during their deferral while
individual engages in multitasking
Comparative Anatomy
• Expanded size and cell density in humans compared to

nonhuman primates
• Phylogenetically young region
Abstraction
• More abstract cognitive thought is performed more

anteriorly within prefrontal cortex with frontopolar cortex at
apex
Tracer/Diffusion Tensor Imaging Studies
• Poor characterization of distant area 10 inputs/outputs in

human and macaque
• Reciprocal connections are with dorsolateral, orbitofrontal,
and medial prefrontal cortex
• Hierarchical, rostrocaudal connectivity
Rostral frontal areas connected to intermediate ones
that, in turn, connect to more caudal frontal areas
Coactive Regions
• Medial Fp (especially Fp2) is coactive with default mode

network
Posterior cingulate cortex (area 23, 31)
Inferior parietal lobule (areas 39, 40)
Inferior temporal gyrus (area 20)
• Error related, intentions, remember, thoughts, contextual,

salient, autobiographical, amount, correct, stress, nonverbal

Anterior Cerebral Artery Ischemia
• Common site of injury along with other medial prefrontal

and cingulate regions (especially frontopolar branch)
Traumatic Injury
• Damage to Fp does not impair performance in well-learned,

cognitively demanding tasks
• Can cause behavioral changes for situations requiring
redistribution of resources to novel tasks
Image Gallery
Print Images
BRODMANN AREA 10: FRONTAL POLE
area 10 in over 4,000 studies from the NeuroSynth
database. This image shows the average of left and right
coactivation maps.
Axial and sagittal slices show the relative position of
frontopolar cortex area 10 (WFU PickAtlas).
CONNECTIVITY TO LEFT BRODMANN AREA 10

Functional connectivity to the left Brodmann area 10, lateral
view, is shown. Connectivity to the temporoparietal junction
and middle temporal gyrus, areas of the default network, is
seen.
Functional connectivity to the left Brodmann area 10, left
medial view, shows connectivity to the superior frontal gyrus
and precuneus, areas of the default network.
CONNECTIVITY TO RIGHT BRODMANN AREA 10

correlation to a seed region in the right Brodmann area 10
Image was displayed using BrainNet Viewer software.
Functional connectivity to the right Brodmann area 10,
lateral view, is shown. Connectivity is highest to regions of
the default network: Temporoparietal junction, superior
frontal, and middle and inferior temporal gyri.
Functional connectivity to the right Brodmann area 10, right
medial view, is shown. Connectivity is highest to the
superior frontal, posterior cingulate, and medial superior
parietal regions of the default network.
CONNECTIVITY: BILATERAL FRONTAL POLE

FRONTAL POLE: RENDERED

Frontal surface-rendered map of the frontopolar cortex is
shaded in cyan, representing Brodmann cortical parcellation
scheme for area 10 (Connectome Workbench).
Medial surface-rendered map of the frontopolar cortex is
Lateral surface-rendered map of the frontopolar cortex is
Additional Images
toolbox for MATLAB.
in bilateral Brodmann area 10 as defined by the WFU
(frontal pole). Image was created using BrainNet Viewer
software.
Image was created using BrainNet Viewer software. Robust
connectivity is seen to default mode network hubs in the
medial prefrontal and posterior cingulate cortex.
Frontal surface-rendered view, averaged from the same
Occipital surface-rendered view, averaged from the same
correlation to a seed region in bilateral Brodmann area 10
Selected References
1. Eickhoff, SB, et al. Topographic organization of the cerebral
cortex and brain cartography. Neuroimage. 2018; 170:332–
347.
2. Mansouri, FA, et al. Managing competing goals - a key role
for the frontopolar cortex. Nat Rev Neurosci. 2017;
18(11):645–657.
3. Glasser, MF, et al. A multi-modal parcellation of human
cerebral cortex. Nature. 2016; 536(7615):171–178.
4. Mansouri, FA, et al. Behavioral consequences of selective
damage to frontal pole and posterior cingulate cortices. Proc
Natl Acad Sci U S A. 2015; 112(29):E3940–E3949.
5. Neubert, FX, et al. Connectivity reveals relationship of brain
areas for reward-guided learning and decision making in
human and monkey frontal cortex. Proc Natl Acad Sci U S A.
2015; 112(20):E2695–E2704.
6. Orr, JM, et al, Organization of the human frontal pole
revealed by large-scale DTI-based connectivity: implications
for control of behavior. PLoS One 10 5 2015 e0124797
7. Bludau, S, et al. Cytoarchitecture, probability maps and
functions of the human frontal pole. Neuroimage. 2014;
93(Pt 2):260–275.
10. Semendeferi, K, et al. Spatial organization of neurons in the
frontal pole sets humans apart from great apes. Cereb
Cortex. 2011; 21(7):1485–1497.
11. Tsujimoto, S, et al. Frontal pole cortex: encoding ends at the
end of the endbrain. Trends Cogn Sci. 2011; 15(4):169–176.
12. Burgess, PW, et al. The gateway hypothesis of rostral
prefrontal cortex (area 10) function. Trends Cogn Sci. 2007;
11(7):290–298.
13. John, JP, et al. A proposal for MRI-based parcellation of the
frontal pole. Brain Struct Funct. 2007; 212(3-4):245–253.
14. Gilbert, SJ, et al. Differential functions of lateral and medial
rostral prefrontal cortex (area 10) revealed by brain-
behavior associations. Cereb Cortex. 2006; 16(12):1783–1789.
15. Gilbert, SJ, et al. Functional specialization within rostral
prefrontal cortex (area 10): a meta-analysis. J Cogn Neurosci.
2006; 18(6):932–948.
19(3):1233–1239.
17. Okuda, J, et al. Thinking of the future and past: the roles of
the frontal pole and the medial temporal lobes. Neuroimage.
2003; 19(4):1369–1380.
18. Vogeley, K, et al. Automated image analysis of disturbed
cytoarchitecture in Brodmann area 10 in schizophrenia.
Schizophr Res. 2003; 62(1-2):133–140.
19. Semendeferi, K, et al. Prefrontal cortex in humans and apes:
a comparative study of area 10. Am J Phys Anthropol. 2001;
114(3):224–241.
Orbitofrontal Cortex (Area 11)
Main Text
Location
• Ventral aspect of inferior frontal lobes within anterior

cranial fossa
• Includes orbital gyri and gyrus rectus
• Orbitofrontal cortex among most technical regions to study
with fMRI due to susceptibility artifact
Boundaries
• Dorsal: Frontal pole (area 10)

• Caudal: Subgenual cingulate cortex (area 25) and anterior
cingulate cortex (area 32)
• Lateral: Contiguous with pars orbitalis (area 47) and insula
(area 13)
Divisions
• Function and cytoarchitecture differ between medial and

lateral orbitofrontal cortex
Function
Emotional Processing
• Pleasantness of stimuli represented in orbitofrontal cortex

• Pleasantness of stimuli represented in orbitofrontal cortex
Decision Making and Prediction
• Impaired decision making with orbitofrontal lesions

• Orbitofrontal cortex required to assign reward to outcome
and initiate decision
Response Inhibition
• Lateral orbitofrontal cortex participates in initiation of

response inhibition
Valuation, Reward, and Adaptive Behavior
• Lateral orbitofrontal cortex more active following punishing

outcome
• Medial orbitofrontal cortex more active following rewarding
outcome
• More complex or abstract rewards/punishments represented
more anteriorly
Multimodal Sensory Integration and Hedonic Experience
• Multimodal sensory inputs in posterior lateral orbitofrontal

cortex
• Hedonic rewards encoded more anteriorly in lateral
orbitofrontal cortex
• Also process rewards for abstract stimuli (e.g., music, social,
money)
Medial Orbitofrontal
• Posterior cingulate cortex (areas 23, 31), retrosplenial
cingulate cortex (areas 29, 30), parahippocampal gyrus
(areas 28, 34, 35, and 36), and hippocampus
Lateral Orbitofrontal
• Amygdala, olfactory cortex, gustatory cortex (area 43),

insula (area 13), nucleus accumbens, ventral tegmental area,
inferior temporal gyrus (area 20), somatosensory cortex
(areas 1, 2, and 3), auditory cortex (areas 41, 42), and visual
association cortex (areas 18, 19)
Coactive Regions
• Medial orbitofrontal: Default mode network (i.e., posterior

cingulate cortex (areas 23, 31)/precuneus (areas 5, 7),
temporoparietal junction (areas 39, 40), medial temporal
cortex, lateral temporal cortex (areas 20, 21, and 22),
anterior cingulate cortex (areas 24, 32, 33)
• Lateral orbitofrontal: Dorsolateral prefrontal cortex (areas 9,
46), medial temporal, temporal pole (area 38), anterior
insula (area 13)
• Choices, memories, recollection, concepts, rejection, cocaine,

self-reported, negative, positive, movie, decision, subjective

Traumatic Brain Injury
• Commonly contused in closed-head injury

• Commonly contused in closed-head injury
Frontal Sinus Disorders
• Caused by infections and neoplasms, among other causes

• May result in cerebritis or compression of orbitofrontal
cortex
Addiction
• Stimulating orbitofrontal cortex in animals results in drug

self-administration
Bilateral Orbitofrontal Injury
• Produces severe impairment in learning, changing rewards

associated with stimuli
Image Gallery
Print Images
ORBITOFRONTAL C ORTEX: LOC ATION AND
COACTIVATION
Axial and coronal slices show the relative position of
orbitofrontal cortex area 11 (data source: WFU PickAtlas).
database. Image is the average of left and right coactivation
maps.
CONNECTIVITY TO LEFT ORBITOFRONTAL CORTEX

Medial view shows the correlation to a seed region in the
left Brodmann area 11.
Superior view shows the correlation to a seed region in the
left Brodmann area 11.
CONNECTIVITY TO RIGHT ORBITOFRONTAL CORTEX

Medial view shows the correlation to a seed region in the
Superior view shows the correlation to a seed region in the
BILATERAL ORBITOFRONTAL CORTEX CONNECTIVITY

ORBITOFRONTAL CORTEX: LOCATION

Lateral surface-rendered map of the orbitofrontal cortex is
shaded in violet, representing Brodmann cortical parcellation
scheme for area 11 (data source: Connectome
Workbench).
Ventral surface-rendered map of the orbitofrontal cortex is
shown.
Medial surface-rendered map of the orbitofrontal cortex is
shown.
Additional Images
1,016 typically developing volunteers ages 18-30 from the
1000 Functional Connectomes and ADHD-200 datasets.
Brodmann Area 11, as defined by the WFU PickAtlas
toolbox for MATLAB.
toolbox for MATLAB.
region in bilateral Brodmann area 11, as defined by the
An axial slice at the level of the mammillary bodies shows
functional connectivity to a seed composed of bilateral
orbitofrontal cortex (area 11).
An axial slice above the dorsal margin of the lateral
ventricles shows functional connectivity to a seed composed
of bilateral orbitofrontal cortex (area 11).
Functional connectivity MR averaged from 1,016 typically
developing volunteers (ages 18-30) from 1,000 Functional
Connectomes and ADHD-200 datasets. Left lateral surface
rendering shows correlation to a seed region in bilateral
Brodmann area 11, as defined by WFU PickAtlas toolbox
for MATLAB. Image via BrainNet Viewer software.
(orbitofrontal cortex). Image created using BrainNet Viewer
software.
averaged from the same data, shows functional connectivity
to Brodmann area 11. Image was created using BrainNet
Viewer software.
Selected References
1. Saez, RA, et al. Distinct roles for the amygdala and
orbitofrontal cortex in representing the relative amount of
expected reward. Neuron. 2017; 95(1):70–77.e3.
2. Stalnaker, TA, et al. What the orbitofrontal cortex does not
do. Nat Neurosci. 2015; 18(5):620–627.
3. Smith, DG, et al. Enhanced orbitofrontal cortex function
and lack of attentional bias to cocaine cues in recreational
stimulant users. Biol Psychiatry. 2014; 75(2):124–131.
4. Wilson, RC, et al. Orbitofrontal cortex as a cognitive map of
task space. Neuron. 2014; 81(2):267–279.
7. Uylings, HB, et al. 3-D cytoarchitectonic parcellation of
human orbitofrontal cortex correlation with postmortem
MRI. Psychiatry Res. 2010; 183(1):1–20.
8. Schoenbaum, G, et al. A new perspective on the role of the
orbitofrontal cortex in adaptive behaviour. Nat Rev Neurosci.
2009; 10(12):885–892.
9. Kringelbach, ML. The human orbitofrontal cortex: linking
reward to hedonic experience. Nat Rev Neurosci. 2005;
6(9):691–702.
10. Hornak, J, et al. Reward-related reversal learning after
surgical excisions in orbito-frontal or dorsolateral prefrontal
cortex in humans. J Cogn Neurosci. 2004; 16(3):463–478.
19(3):1233–1239.
12. O’Doherty, J, et al. Abstract reward and punishment
representations in the human orbitofrontal cortex. Nat
Neurosci. 2001; 4(1):95–102.
13. Bechara, A, et al. Emotion, decision making and the
orbitofrontal cortex. Cereb Cortex. 2000; 10(3):295–307.
14. Cavada, C, et al. The anatomical connections of the
macaque monkey orbitofrontal cortex. A review. Cereb
Cortex. 2000; 10(3):220–242.
15. Volkow, ND, et al. Addiction, a disease of compulsion and
drive: involvement of the orbitofrontal cortex. Cereb Cortex.
2000; 10(3):318–325.
Insula and Parainsula Areas (Areas
13, 43)
Main Text
Locations and Boundaries
Location
• Anterior portion of parietal operculum (secondary

somatosensory cortex, area 43)
• Cortex underlying lateral sulcus (insula, area 13)
Boundaries
• Caudal and ventral: Temporal operculum

• Caudal and dorsal: Parietal operculum
• Rostral and dorsal: Frontal operculum
• Surrounded by temporal pole (area 38), superior temporal
gyrus (area 22), auditory cortex (areas 41 and 42), primary
somatosensory cortex (areas 1, 2, and 3), premotor cortex
(area 6), inferior frontal gyrus (areas 44, 45, and 47), and
orbitofrontal cortex (area 11)
Function
Interoception
• Thirst
• Oxygen deprivation
• Sexual arousal
• Distension of organs involved in food consumption and
digestion
• Heartbeat
• Itch
Salience
• Presentation of novel stimulus

• Monitoring of task performance
Emotion
• Sadness, disgust, fear, negatively and positively valenced

stimuli, joy, love, empathy, etc.
Somatosensation
• Fine touch
Multiple somatotopic maps of body represented in
secondary somatosensory cortex (area 43) and insula
(area 13), separate from somatotopic map in primary
somatosensory cortex (areas 1, 2, and 3)
Somatotopic map in insula represents subjective
somatosensory and motor experience
• Texture perception
Nociception (pain perception)
Thermoception (temperature perception)
Somatosensory working memory
Integration of sensory and motor processing
Proprioception
Music
• Rhythm, pitch, and timbre
• Singing
Gustation
• Processing of taste perception
Time Passage
• Perception of time passage becomes more keen (i.e., dilation

of time) during salient and emotional experiences
• Time synchronization
Cortical

• Temporal cortex (areas 20, 21, and 22)
• Inferior frontal gyrus (areas 44 and 45)
• Inferior parietal lobule (areas 39 and 40)
• Superior parietal lobule (areas 5 and 7)
• Entorhinal cortex (areas 28, 35, and 36)
Subcortical
• Ventral medial nucleus of thalamus

• Ventral posterior inferior nucleus of thalamus
• Amygdala
• Hippocampus
• Basal ganglia
Coactive Regions

• Dorsolateral prefrontal cortex (areas 9 and 46)
• Thalamus
• Basal ganglia
• Cerebellum
• Pain, noxious, unpleasant, somatosensory, heat,

temperature, stimulation, vocal, tactile, rating, pitch,
sensation

Fibromyalgia
• Inability to modulate painful stimuli
Addiction
• Conscious urge to take drugs involves insular activity

Anxiety Conditions
• Hyperactivity in anxiety conditions

Generalized anxiety disorder
Posttraumatic stress disorder
Social anxiety disorder
Specific phobia
Image Gallery
Print Images
INSULA: LOCATION AND COACTIVATION
posterior insular cortex is shown. This quantitative
brains and is specific to cellular properties unique to area
13 (data source: SPM Anatomy toolbox).
Coactivation map of Brodmann areas 13 and 43 shows

brain regions that reliably activate with the centroid of
voxels lying within areas 13 and 43 in over 4,000 studies
from the NeuroSynth database. Image is the average of left
and right coactivation maps.
FUNCTIONAL PARCELLATION OF INSULA
A parcellation of the insula into 6 regions (superior, inferior,

anterior, mid, and posterior) is shown. Clustering is based
on functional connectivity to the cortex. Anterior insular
regions show greatest connectivity to the dorsal attention
network (superior) and default network (inferior). Mid insular
regions show greatest connectivity to the salience network
(superior) and medial temporal and limbic structures
(inferior). Posterior insular regions show greatest
connectivity to the somatomotor, auditory, and visual cortex.
Parcellation of the cerebral cortex shows which region of

the insula exhibits the highest connectivity to each subregion
of the cortex.
FUNCTIONAL SUBREGIONS AND LOCATION OF INSULA

Map of the cerebral cortex shows which subregion of the
insula exhibits the highest connectivity to each cortical
territory.
Lateral surface rendering of a cytoarchitectonic map for the
gustatory cortex shows a quantitative probabilistic map that
is derived from postmortem human brains and specific to
cellular properties unique to area 43 (data source: JuBrain
FUNCTIONAL CONNECTIVITY TO AREA 13

a seed region in the left Brodmann area 13 as defined by
Correlation to a seed region in the bilateral Brodmann area
13 is shown.
AREAS 13 AND 43: LOCATION

the gustatory cortex are shown. This quantitative
brains and is specific to cellular properties unique to area
43 (data source: SPM Anatomy toolbox).
Axial slices show the relative positions of insular area 13
(blue) and parainsular area 43 (red) (data source: WFU
PickAtlas).
Coronal and sagittal slices show the relative positions of
insular area 13 (blue) and parainsular area 43 (red) (data
source: WFU PickAtlas).
Additional Images
region in the right Brodmann area 43 as defined by the
datasets. The image shows the correlation to a seed region
PickAtlas toolbox for MATLAB. This image was created
This image shows the correlation to a seed region in
bilateral Brodmann area 13 as defined by the WFU
datasets. This image shows the correlation to a seed region
PickAtlas toolbox for MATLAB. Area 43 is located at the far
lateral margin of the central sulcus within the lateral sulcus
of the insula and contains the gustatory cortex.
Axial slices from a cytoarchitectonic map of the gustatory
cortex are shown. This quantitative probabilistic map was
derived from postmortem human brains and is specific to
cellular properties unique to area 43 (data source: SPM
Anatomy toolbox).
Lateral surface-rendered map of the inferior frontal gyrus is
shaded in red, representing Brodmann cortical parcellation
Workbench).
Selected References
1. Gogolla, N. The insular cortex. Curr Biol. 2017; 27(12):R580–
R586.
2. Uddin, LQ, et al. Structure and function of the human
insula. J Clin Neurophysiol. 2017; 34(4):300–306.
3. Caseras, X, et al. Anatomical and functional overlap within
the insula and anterior cingulate cortex during
interoception and phobic symptom provocation. Hum Brain
Mapp. 2013; 34(5):1220–1229.
4. Kamping, S, et al. Deficient modulation of pain by a
positive emotional context in fibromyalgia patients. Pain.
2013; 154(9):1846–1855.
5. Klumpp, H, et al. Insula reactivity and connectivity to
anterior cingulate cortex when processing threat in
generalized social anxiety disorder. Biol Psychol. 2012;
89(1):273–276.
7. Veit, R, et al. Using real-time fMRI to learn voluntary
regulation of the anterior insula in the presence of threat-
related stimuli. Soc Cogn Affect Neurosci. 2012; 7(6):623–634.
8. Carlson, JM, et al. Feeling anxious: anticipatory amygdalo-
insular response predicts the feeling of anxious anticipation.
Soc Cogn Affect Neurosci. 2011; 6(1):74–81.
9. Cauda, F, et al. Functional connectivity of the insula in the
resting brain. Neuroimage. 2011; 55(1):8–23.
10. Corradi-Dell’Acqua, C, et al. Felt and seen pain evoke the
same local patterns of cortical activity in insular and
cingulate cortex. J Neurosci. 2011; 31(49):17996–18006.
11. Kang, Y, et al. Physical temperature effects on trust
behavior: the role of insula. Soc Cogn Affect Neurosci. 2011;
6(4):507–515.
13. Morrison, I, et al. Vicarious responses to social touch in
posterior insular cortex are tuned to pleasant caressing
speeds. J Neurosci. 2011; 31(26):9554–9562.
14. Riem, MM, et al. Oxytocin modulates amygdala, insula, and
inferior frontal gyrus responses to infant crying: a
randomized controlled trial. Biol Psychiatry. 2011;
70(3):291–297.
15. Veldhuizen, MG, et al. The anterior insular cortex
represents breaches of taste identity expectation. J Neurosci.
2011; 31(41):14735–14744.
16. Kurth, F, et al. Cytoarchitecture and probabilistic maps of
the human posterior insular cortex. Cereb Cortex. 2010;
20(6):1448–1461.
17. Craig, AD. How do you feel--now? The anterior insula and
human awareness. Nat Rev Neurosci. 2009; 10(1):59–70.
18. von dem Hagen, EA, et al. Leaving a bad taste in your
mouth but not in my insula. Soc Cogn Affect Neurosci. 2009;
4(4):379–386.
19. Etkin, A, et al. Functional neuroimaging of anxiety: a meta-
analysis of emotional processing in PTSD, social anxiety
disorder, and specific phobia. Am J Psychiatry. 2007;
164(10):1476–1488.
19(3):1233–1239.
Primary Visual and Visual
Association Cortex (Areas 17, 18, 19)
Main Text
Location
• Occipital lobe
Lingual gyrus
Cuneus
Occipital pole
Posterior portion of fusiform gyrus
Superior occipital gyrus
Middle occipital gyrus
Inferior occipital gyrus
Descending occipital gyrus
Boundaries
• Medial: Parietooccipital sulcus

• Ventral: Preoccipital notch
• Lateral: Arbitrary line connecting preoccipital notch and
superior extent of parietooccipital sulcus
• Surrounded by superior parietal lobule (area 7), posterior
cingulate cortex (area 30), inferior temporal gyrus (area 20),
fusiform gyrus (area 37), and angular gyrus (area 39)
Function
Vision
• Edge detection
• Orientation selective
• Perception of motion
• Color perception
• As visual information progresses down visual processing
streams (i.e., "where" or "how" path from areas 17, 18, and
19 into parietal cortex and "what" path from areas 17, 18,
and 19 into temporal cortex), binding of visual features into
single coherent percept occurs
• Retinotopic map exists in primary visual cortex (area 17),
and similar maps exist in association visual cortex (areas 18
and 19)
Cortical
• Superior parietal lobule (areas 5 and 7) via cingulum

• Temporal pole (area 38), anterior inferior temporal gyrus
(area 20), anterior middle temporal gyrus (area 21), and
parahippocampal gyrus (areas 28, 35, and 36) via inferior
longitudinal fasciculus
• Inferior frontal gyrus (areas 44, 45, and 47), orbitofrontal
cortex (area 11), and frontal pole (area 10) via inferior
frontooccipital fasciculus
Subcortical
• Lateral geniculate nucleus of thalamus

• Hippocampus and amygdala via inferior longitudinal
fasciculus
• Pulvinar nucleus of thalamus
Coactive Regions

• Frontal eye fields (area 6)
• Cerebellum
• Thalamus
• Intraparietal sulcus (areas 5 and 7)
• Visual, motion, perception, videos, biological, object, body,

eye, attention, distractors
Areas 17-, 18-, 19-Associated Disorders

Cortical Vision Loss
• Blindness in part of or across entire visual field, depending

on extent of lesion
• Blindness occurs in visual field opposite to side of lesion
Image Gallery
Print Images
VISUAL CORTEX: LOCATION AND COACTIVATION
Sagittal and axial slices from a cytoarchitectonic map of the
visual cortex is shown. This quantitative probabilistic map
was derived from postmortem human brains and is specific
to cellular properties unique to areas 17 and 18 (data
Coactivation map of the visual cortex shows brain regions
that reliably activate in published studies with high loading of
the term "visual" in over 4,000 studies from the NeuroSynth
database.
VISUAL CORTEX: FUNCTIONAL CONNECTIVITY

image shows the correlation to a seed region in bilateral
Brodmann areas 17, 18, and 19 as defined by the WFU
FUNCTIONAL CONNECTIVITY TO VISUAL CORTEX

VISUAL CORTEX: LOCATION AND SUBREGIONS

Ventral surface rendering of a cytoarchitectonic map of the
visual cortex shows a quantitative probabilistic map, derived
from postmortem human brains, that is specific to cellular
properties unique to areas 17, 18, and 19 (data source:
JuBrain Cytoarchitectonic Atlas Viewer).
visual cortex shows a quantitative probabilistic map, derived
from postmortem human brains, that is specific to cellular
properties unique to areas 17, 18, and 19 (data source:
Caudal surface-rendered map of the visual cortex is shaded
in yellow (areas 17 and 18) and gold (area 19) (data
FUNCTIONAL VISUAL SUBREGIONS

Medial surface-rendered map of the visual cortex is shaded
in yellow (areas 17 and 18) and gold (area 19) (data
Medial surface-rendered view created with FreeSurfer
software from a single subject's data shows primary visual
cortex (V1, red) and extrastriate visual cortex (V2/V3, blue).
Lateral surface-rendered view created with FreeSurfer
software from a single subject's data shows extrastriate
visual cortex (V2/V3, blue) and area V5/MT (yellow).
Additional Images
Ventral surface rendering of cytoarchitectonic map of visual
cortex is shown, representing quantitative probabilistic map
derived from postmortem human brains that is specific to
Medial surface rendering of cytoarchitectonic map of visual
Posterior surface rendering of cytoarchitectonic map of
visual cortex is shown, representing quantitative probabilistic
map derived from postmortem human brains that is specific
to cellular properties unique to area 18 (data source:
Medial surface rendering of cytoarchitectonic map of visual
Posterior surface rendering of cytoarchitectonic map of
visual cortex is shown, representing quantitative probabilistic
map derived from postmortem human brains that is specific
to cellular properties unique to area 17 (data source:
Inferior surface rendering of a cytoarchitectonic map of the
visual cortex is shown, representing a quantitative
that is specific to cellular properties unique to area 17 (data
source: JuBrain Cytoarchitectonic Atlas Viewer).
Dorsal surface map of visual cortex represents Brodmann
cortical parcellation scheme for areas 17 (light yellow), 18
(yellow), and 19 (dark yellow) (data source: Connectome
Workbench).
Ventral surface map of visual cortex represents Brodmann
Workbench).
Lateral surface map of visual cortex represents Brodmann
Workbench).
to a seed region in the right Brodmann area 19 as defined
toolbox for MATLAB.
toolbox for MATLAB.
toolbox for MATLAB.
toolbox for MATLAB.
toolbox for MATLAB.
toolbox for MATLAB.
Selected References
1. Han, Y, et al. The logic of single-cell projections from visual
cortex. Nature. 2018; 556(7699):51–56.
2. Iacaruso, MF, et al. Synaptic organization of visual space in
primary visual cortex. Nature. 2017; 547(7664):449–452.
3. Weiner, KS, et al. The cytoarchitecture of domain-specific
regions in human high-level visual cortex. Cereb Cortex.
2017; 27(1):146–161.
4. Cross, ES, et al. The influence of visual training on
predicting complex action sequences. Hum Brain Mapp.
2013; 34(2):467–486.
5. Kujovic, M, et al. Cytoarchitectonic mapping of the human
dorsal extrastriate cortex. Brain Struct Funct. 2013;
218(1):157–172.
6. Bedny, M, et al. A sensitive period for language in the visual
cortex: distinct patterns of plasticity in congenitally versus
late blind adults. Brain Lang. 2012; 122(3):162–170.
7. Brooks, SJ, et al. Exposure to subliminal arousing stimuli
induces robust activation in the amygdala, hippocampus,
anterior cingulate, insular cortex and primary visual cortex:
a systematic meta-analysis of fMRI studies. Neuroimage.
2012; 59(3):2962–2973.
8. Kuchinsky, SE, et al. Word intelligibility and age predict
visual cortex activity during word listening. Cereb Cortex.
2012; 22(6):1360–1371.
9. Langner, R, et al. Staying responsive to the world: modality-
specific and -nonspecific contributions to speeded auditory,
tactile, and visual stimulus detection. Hum Brain Mapp.
2012; 33(2):398–418.
10. Samson, F, et al. Enhanced visual functioning in autism: an
ALE meta-analysis. Hum Brain Mapp. 2012; 33(7):1553–
1581.
11. Schölvinck, ML, et al. The influence of spontaneous activity
on stimulus processing in primary visual cortex.
Neuroimage. 2012; 59(3):2700–2708.
13. Chapman, CS, et al. Mental blocks: fMRI reveals top-down
modulation of early visual cortex when obstacles interfere
with grasp planning. Neuropsychologia. 2011; 49(7):1703–
1717.
15. Schmid, C, et al. The neural basis of visual dominance in the
context of audio-visual object processing. Neuroimage. 2011;
55(1):304–311.
16. Szwed, M, et al. Specialization for written words over
objects in the visual cortex. Neuroimage. 2011; 56(1):330–
344.
17. Rottschy, C, et al. Ventral visual cortex in humans:
cytoarchitectonic mapping of two extrastriate areas. Hum
Brain Mapp. 2007; 28(10):1045–1059.
18. Amunts, K, et al. Brodmann’s areas 17 and 18 brought into
stereotaxic space-where and how variable? Neuroimage.
2000; 11(1):66–84.
Temporal Cortex (Areas 20, 21, 22)
Main Text
Location
• Temporal lobe, from posterior margin of temporopolar

cortex to occipitotemporal junction
Part of superior temporal gyrus represented by primary
auditory cortex (areas 41 and 42)
Boundaries
• Rostral: Extends ~ 2.5 cm from temporal pole (area 38)

• Medial and caudal: Occipitotemporal sulcus separating
occipitotemporal area 37 (posteriorly) and ectorhinal area
36 (anteriorly) from areas 20, 21
• Superior temporal sulcus separates superior temporal area
22 from middle temporal (MT) area 21
• Inferior temporal sulcus separates inferior temporal area 20
from MT area 21
• Angular gyrus (area 39) represents caudal extension of
superior temporal gyrus area 22
Function
Heterogeneous Function
• Auditory association superiorly, visual association inferiorly,
multimodal and attentional association cortex posteriorly
and at temporal pole
• Several highly specialized regions, such as MT area and
Wernicke area
Auditory Processing
• Superior and MT gyri include auditory association cortex

with higher order auditory feature discrimination
Language
• Wernicke area (posterior superior and MT gyrus, posterior

superior temporal sulcus) active during receptive language
Motion Perception and Attention
• MT area active for moving stimuli; participates in dorsal

attention network
High-Order Visual Processing (Ventral "What" Pathway)
• Inferior temporal cortex represents progressively more

complex visual features anteriorly
Social Cognition
• Superior temporal sulcus and frontopolar regions frequently

active in social activation paradigms
Inputs
• Visual inputs from lateral occipital lobe ("what" pathway):
• Visual inputs from lateral occipital lobe ("what" pathway):
Fusiform gyrus (area 37) and extrastriate cortex (areas 18
and 19)
• Auditory inputs from primary auditory cortex (areas 41, 42)
to superior and MT gyri
Reciprocal Connections
• Language regions (Broca, Wernicke) with dense

interconnectivity throughout inferior frontal (areas 44, 45,
and 47), temporal, inferior parietal (areas 39 and 40), and
insular (area 13) cortices
• Attentional regions: Lateral middle and inferior temporal
gyri with default mode network, posterior MT area with
dorsal attention network
Coactive Regions
• Attention control network with MT area

• Sensorimotor network with superior temporal gyrus near
primary auditory cortex (areas 41 and 42)
• Language network near Wernicke area
• Default mode network with inferior and MT cortex more
anteriorly
Associated Literature Keywords (NeuroSynth, Area 21)
• Self-referential, text, elderly, engagement, retrieval, thought,

attribution, story, conceptual, lexical, theory of mind

Wernicke Aphasia
• Inability to comprehend speech of others; preserved fluency
but often meaningless speech ("word salad")
Image Gallery
Print Images
TEMPORAL CORTEX: LOCATION AND COACTIVATION
Axial and coronal slices show the relative positions of

superior, middle, and inferior temporal gyri representing
Brodmann areas 22, 21, and 20, respectively (data source:
WFU PickAtlas).
Coactivation map of Brodmann areas 20, 21, and 22 shows

voxels lying within areas 20, 21, and 22 in over 4,000
studies from the NeuroSynth database. This image is the
average of left and right coactivation maps.
TEMPORAL CORTEX CONNECTIVITY

datasets. This image shows the correlation to a seed region
in bilateral Brodmann areas 20, 21, and 22 as defined by
Slices show the correlation to a seed region in the bilateral
Brodmann area 22.
BRODMANN AREAS 20, 21, AND 22

Lateral surface-rendered map of the superior temporal
gyrus is shaded in green, representing Brodmann cortical
Workbench).
Lateral surface-rendered map of the middle temporal gyrus
is shaded in green, representing Brodmann cortical
Workbench).
Ventral surface-rendered map, with cerebellum removed, of
the inferior temporal gyrus is shaded in olive green,
area 20 (data source: Connectome Workbench).
TEMPORAL GYRI AND SULCI

Sagittal section of a temporal cortex map represents
Brodmann cortical parcellation scheme for areas 20, 21,
and 22 (data source: WFU PickAtlas).
Lateral surface-rendered image shows superior (blue),
middle (red), and inferior (yellow) temporal gyri,
reconstructed in FreeSurfer software package using
Destrieux 2009 atlas for 1 subject.
Lateral-rendered image of the white matter surface shows
superior (blue), middle (red), and inferior (yellow) temporal
gyri and superior (orange) and inferior (green) temporal
sulci reconstructed in FreeSurfer software package using
Destrieux 2009 atlas for 1 subject.
Additional Images
Sagittal section of a temporal cortex map represents
Brodmann cortical parcellation scheme for areas 20, 21,
and 22 (data source: WFU PickAtlas).
Ventral surface-rendered map, with cerebellum removed, of
the inferior temporal gyrus is shaded in green, representing
PickAtlas toolbox for MATLAB. Connectivity is strongest
with the default mode network.
PickAtlas toolbox for MATLAB. Connectivity is strongest
with language regions and the ventral attention network.
Selected References
1. Bonilha, L, et al. Temporal lobe networks supporting the
comprehension of spoken words. Brain. 2017; 140(9):2370–
2380.
2. Murphy, C, et al. Fractionating the anterior temporal lobe:
MVPA reveals differential responses to input and
conceptual modality. Neuroimage. 2017; 147:19–31.
5. Destrieux, C, et al. Automatic parcellation of human
cortical gyri and sulci using standard anatomical
nomenclature. Neuroimage. 2010; 53(1):1–15.
6. Dahl, CD, et al. Spatial organization of multisensory
responses in temporal association cortex. J Neurosci. 2009;
29(38):11924–11932.
7. Hein, G, et al. Superior temporal sulcus--it’s my area: or is
it? J Cogn Neurosci. 2008; 20(12):2125–2136.
8. Hickok, G, et al. The cortical organization of speech
processing. Nat Rev Neurosci. 2007; 8(5):393–402.
9. Zilbovicius, M, et al. Autism, the superior temporal sulcus
and social perception. Trends Neurosci. 2006; 29(7):359–366.
10. Kable, JW, et al. Conceptual representations of action in the
lateral temporal cortex. J Cogn Neurosci. 2005; 17(12):1855–
1870.
11. Kraemer, DJ, et al. Musical imagery: sound of silence
activates auditory cortex. Nature. 2005; 434(7030):158.
12. Catani, M, et al. Occipito-temporal connections in the
human brain. Brain. 2003; 126(Pt 9):2093–2107.
19(3):1233–1239.
14. Buckner, RL, et al. Functional MRI evidence for a role of
frontal and inferior temporal cortex in amodal components
of priming. Brain. 2000; 123(Pt 3):620–640.
15. Kim, JJ, et al. An MRI-based parcellation method for the
temporal lobe. Neuroimage. 2000; 11(4):271–288.
16. Nobre, AC, et al. Word recognition in the human inferior
temporal lobe. Nature. 1994; 372(6503):260–263.
17. Lüders, H, et al. Basal temporal language area. Brain. 1991;
114(Pt 2):743–754.
Posterior Cingulate Cortex (Areas 23,
31)
Main Text
Location
• Posterior cingulate gyrus

• Functionally related to adjacent precuneus and retrosplenial
cortex
Boundaries
• Ventral: Ventral margin of splenium of corpus callosum

(retrosplenial areas 29, 30 extend ventrally)
• Rostral: Midcingulate/posterior cingulate border varies
between midpoint of corpus callosum to plane of central
sulcus to marginal sulcus
• Dorsal: Subparietal sulcus separates precuneus (medial
portion of area 7) from posterior cingulate cortex
• Caudal: Parietooccipital sulcus
• Surrounded by anterior cingulate cortex (area 24), primary
motor cortex (area 4), supplementary motor area (area 6),
retrosplenial cingulate cortex (areas 29 and 30), visual cortex
(area 19)
Function
Self-Referential Cognition
• Midline core of default mode network (i.e., medial

prefrontal, posterior cingulate, temporoparietal junction,
lateral temporal) processes internally directed thought
Declarative Memory
• Medial temporal subsystem of default mode network (i.e.,

parahippocampal regions, retrosplenial cortex, posterior
inferior parietal cortex) participates in constructing mental
scene from memory
Internal Narrative
• Robust connections between default mode network

(especially left temporoparietal junction and posterior
cingulate) and left-hemispheric language regions likely add
semantic information to language
Anterior Precuneus
• Superior parietal cortex (areas 5 and 7), paracentral lobule,

and motor cortex (area 4)
Central Precuneus
• Dorsolateral prefrontal cortex (areas 9 and 46), dorsomedial

prefrontal cortex, and inferior parietal lobule (areas 39 and
40)
Posterior Precuneus
• Extrastriate visual cortex (areas 18 and 19)
Ventral Posterior Cingulate
• Medial temporal, lateral temporal cortex (areas 20, 21, and

22), inferior parietal lobule (areas 39 and 40), medial
prefrontal cortex
Coactive Regions
• Regions of default mode network: Medial prefrontal cortex,

inferior parietal lobule (areas 39 and 40), lateral temporal
cortex, hippocampus and parahippocampal gyrus (areas 28,
34, 35, and 36), temporal pole (area 38)
• Self-referential, autobiographical, person, self, recollection,

default, moral, memory, facial, sensation, episodic, retrieval,
perspective

Alzheimer Dementia
• Decreased functional connectivity and focal atrophy is

present in posterior cingulate cortex
• Functional connectivity abnormalities in default mode
network precede behavioral changes
Epilepsy
• Connectivity between hippocampus and posterior cingulate

• Connectivity between hippocampus and posterior cingulate
predicts improved outcome following temporal lobectomy
Autism, Down Syndrome, Schizophrenia
• Connectivity with posterior cingulate is most predictive of

abnormality in many neurodevelopmental and
neuropsychiatric disorders
Image Gallery
Print Images
POSTERIOR C INGULATE: LOC ATION AND
COACTIVATION
Coronal and axial slices show the relative positions of
posterior cingulate cortex areas 23 and 31 (data source:
WFU PickAtlas).
C ONNEC TIVITY TO RIGHT POSTERIOR C INGULATE

CORTEX
Medial surface rendering shows the correlation to a seed
region in the right Brodmann area 31.
Superior surface rendering shows the correlation to a seed
CONNECTIVITY TO POSTERIOR CINGULATE CORTEX

Left lateral surface-rendered view, averaged from the same
Greater connectivity is seen to temporoparietal junction
default mode network hubs than for area 23.
POSTERIOR C INGULATE: LOC ATION AND

CONNECTIVITY
Surface-rendered map of the inferior frontal gyrus is shaded
in purple, representing Brodmann cortical parcellation
scheme for areas 23 (blue) and 31 (purple). Area 31
includes the dorsal posterior cingulate cortex, and area 23
includes the ventral posterior cingulate cortex (data source:
Additional Images
toolbox for MATLAB.
toolbox for MATLAB.
lateral surface-rendered view shows correlation to a seed
region in bilateral Brodmann area 23 as defined by WFU
PickAtlas toolbox for MATLAB. Image created using
A single axial slice shows functional connectivity MR
region in bilateral Brodmann area 23 as defined by the WFU
Axial slice shows functional connectivity to a seed region in
bilateral Brodmann area 31.
Axial slice, near the dorsal margin of the lateral ventricles,
shows functional connectivity to a seed region in bilateral
Brodmann area 23.
Axial slice, near the dorsal margin of the lateral ventricles,
Brodmann area 31.
Axial slice, above the dorsal margin of the lateral ventricles,
Brodmann area 31.
Selected References
1. Cunningham, SI, et al. Structural and functional
connectivity of the precuneus and thalamus to the default
mode network. Hum Brain Mapp. 2017; 38(2):938–956.
2. Guterstam, A, et al. Posterior cingulate cortex integrates the
senses of self-location and body ownership. Curr Biol. 2015;
25(11):1416–1425.
3. Mansouri, FA, et al. Behavioral consequences of selective
damage to frontal pole and posterior cingulate cortices. Proc
Natl Acad Sci U S A. 2015; 112(29):E3940–E3949.
4. Khalsa, S, et al. The structural and functional connectivity
of the posterior cingulate cortex: comparison between
deterministic and probabilistic tractography for the
investigation of structure-function relationships.
Neuroimage. 2014; 102(Pt 1):118–127.
5. Taylor, VA, et al. Impact of meditation training on the
default mode network during a restful state. Soc Cogn Affect
Neurosci. 2013; 8(1):4–14.
6. Mars, RB, et al. On the relationship between the “default
mode network” and the “social brain”. Front Hum Neurosci.
2012; 6:189.
8. Anderson, JS, et al. Connectivity gradients between the
default mode and attention control networks. Brain Connect.
2011; 1(2):147–157.
10. Petrella, JR, et al. Default mode network connectivity in
stable vs progressive mild cognitive impairment. Neurology.
2011; 76(6):511–517.
65(4):550–562.
12. Greicius, MD, et al. Resting-state functional connectivity
reflects structural connectivity in the default mode network.
Cereb Cortex. 2009; 19(1):72–78.
13. Margulies, DS, et al. Precuneus shares intrinsic functional
architecture in humans and monkeys. Proc Natl Acad Sci U
S A. 2009; 106(47):20069–20074.
1124:1–38.
15. Fransson, P, et al. The precuneus/posterior cingulate cortex
plays a pivotal role in the default mode network: evidence
from a partial correlation network analysis. Neuroimage.
2008; 42(3):1178–1184.
16. Cavanna, AE, et al. The precuneus: a review of its functional
anatomy and behavioural correlates. Brain. 2006; 129(Pt
3):564–583.
17. Greicius, MD, et al. Default-mode network activity
distinguishes Alzheimer’s disease from healthy aging:
evidence from functional MRI. Proc Natl Acad Sci U S A.
2004; 101(13):4637–4642.
19(3):1233–1239.
19. Raichle, ME, et al. A default mode of brain function. Proc
Natl Acad Sci U S A. 2001; 98(2):676–682.
Anterior Cingulate Cortex (Areas 24,
32, 33)
Main Text
Location
• Cingulate gyrus from genu of corpus callosum to level of

marginal sulcus
• Area 33: Callosal surface of cingulate gyrus
• Area 24: Mid substance of cingulate gyrus, extends furthest
caudally
• Area 32: Outer cingulate gyrus, extends furthest rostrally
Boundaries
• Dorsal: Bounded by cingulate sulcus

• Rostral: Includes pregenual cingulate cortex, continuous
with subgenual cingulate (area 25)
• Caudal: Variable anterior/posterior cingulate boundary in
literature
Anterior cingulate cortex (ACC)/posterior cingulate
cortex (PCC) division ranges from midpoint of corpus
callosum to marginal sulcus
• Surrounded by subgenual cingulate cortex (area 25),
orbitofrontal cortex (area 11), frontal pole (area 10),
dorsolateral prefrontal cortex (area 9), superior prefrontal
cortex (area 8), supplementary motor area (area 6), PCC
(areas 23 and 31)
Divisions
• ACC
• Mid cingulate cortex (MCC): Can be subdivided into
anterior and posterior regions
Also termed caudal or dorsal ACC
Different function, cytoarchitecture, and connectivity
from ACC
ACC/MCC histological border approximately bisects
ACC
• ~ 30 cytoarchitectonic regions described in cingulate gyrus
in literature
Function
Emotional Perception and Regulation
• Functional activation greater for happy emotional responses

in pregenual ACC, greater for sad emotional responses in
subgenual ACC
Salience Detection
• MCC is core hub of salience detection network with bilateral

superior mid insula
• Increasing emotive salience anteriorly in ACC, inferiorly in
insula
Empathy
• Unclear if demonstrated activity during empathic reasoning

in ACC represents empathy or greater salience of stimuli
• Core empathic reasoning more associated with anterior
insula
Impulse Control
• Anterior cingulate acts as motor arm of response inhibition

and impulse control
Autonomic, Temperature, and Pain Perception
• Both valence and affective components of interoceptive

signals are represented
Reward, Valuation, and Decision Making
• Error detection associated with activity in posterior ACC

and MCC
• Insula (area 13), supplementary motor area (area 6), PCC

(areas 23 and 31), frontal pole (area 10), dorsolateral
prefrontal cortex (areas 9 and 46), striatum, orbitofrontal
cortex (area 11), amygdala
Coactive Regions
• Ventral attention network: Anterior and mid insula (area

13), dorsolateral prefrontal cortex (areas 9 and 46), inferior
frontal gyrus (areas 44, 45, and 47), inferior parietal lobule
(areas 39 and 40)
• Painful, automatic, noxious, heat, money, phasic, saccadic,

subjective, inference, shock, temperature

Addiction
• Attenuated ACC error signals and impulse control in

addictive populations
Psychiatry
• Altered ACC connectivity and activity in obsessive

compulsive disorder, schizophrenia, pain syndromes, panic
disorder, posttraumatic stress disorder, and attention deficit
hyperactivity disorder
Image Gallery
Print Images
ANTERIOR CINGULATE CORTEX
Medial surface-rendered map shows inferior frontal gyrus
(purple), representing Brodmann cortical parcellation
scheme for areas 24 (blue), 32 (light blue), and 33 (purple).
Brodmann areas include both anterior cingulate and mid
cingulate cortex (data source: Connectome Workbench).
Medial-rendered view shows boundaries of anterior
cingulate cortex (red), anterior mid cingulate cortex (blue),
and posterior mid cingulate cortex (yellow) from Destrieux
atlas in 1 subject.
datasets. The images show correlation to seed regions in
bilateral Brodmann areas 24, 32, and 33 as defined by the
WFU PickAtlas toolbox for MATLAB. Images were created
ANTERIOR CINGULATE CORTEX: COACTIVATION

Axial and coronal sections of anterior cingulate cortex are
displayed, including Brodmann cortical parcellation scheme
for areas 24, 32, and 33 (data source: WFU PickAtlas).
studies from the NeuroSynth database. Image is the
CONNECTIVITY TO LEFT ANTERIOR CINGULATE CORTEX

Project dataset. Lateral surface renderings show correlation
Correlation to a seed region in the left Brodmann area 32 is
shown.
CONNECTIVITY: BILATERAL BRODMANN AREA 24

CONNECTIVITY: BILATERAL BRODMANN AREA 32

Additional Images
image shows the correlation to a seed region in bilateral
Brodmann area 24 as defined by WFU PickAtlas toolbox for
MATLAB. Left lateral surface-rendered view is shown. This
image was created using BrainNet Viewer software.
Right lateral surface-rendered view, averaged from the
same data, shows functional connectivity to Brodmann area
24. This image was created using BrainNet Viewer
software.
This image was created using BrainNet Viewer software.
The image shows the correlation to a seed region in
PickAtlas toolbox for MATLAB. Connectivity is greatest in a
local distribution within the anterior cingulate cortex.
PickAtlas toolbox for MATLAB. Connectivity is seen with
anterior insula and frontopolar cortex.
PickAtlas toolbox for MATLAB. Robust connectivity is seen
with the anterior insula (salience network).
Selected References
1. Braem, S, et al. The role of anterior cingulate cortex in the
affective evaluation of conflict. J Cogn Neurosci. 2017;
29(1):137–149.
2. Heilbronner, SR, et al. Dorsal anterior cingulate cortex: a
bottom-up view. Annu Rev Neurosci. 2016; 39:149–170.
3. Shenhav, A, et al. Dorsal anterior cingulate cortex and the
value of control. Nat Neurosci. 2016; 19(10):1286–1291.
4. Barthas, F, et al. The anterior cingulate cortex is a critical
hub for pain-induced depression. Biol Psychiatry. 2015;
77(3):236–245.
5. Chudasama, Y, et al. The role of the anterior cingulate
cortex in choices based on reward value and reward
contingency. Cereb Cortex. 2013; 23(12):2884–2898.
6. Gu, X, et al. Anterior insular cortex is necessary for
empathetic pain perception. Brain. 2012; 135(Pt 9):2726–
2735.
9. Yu, C, et al. Functional segregation of the human cingulate
cortex is confirmed by functional connectivity based
neuroanatomical parcellation. Neuroimage. 2011;
54(4):2571–2581.
10. Beckmann, M, et al. Connectivity-based parcellation of
human cingulate cortex and its relation to functional
specialization. J Neurosci. 2009; 29(4):1175–1190.
11. Kelly, AM, et al. Development of anterior cingulate
functional connectivity from late childhood to early
adulthood. Cereb Cortex. 2009; 19(3):640–657.
12. Taylor, KS, et al. Two systems of resting state connectivity
between the insula and cingulate cortex. Hum Brain Mapp.
2009; 30(9):2731–2745.
13. Vogt, BA, et al. Cingulate Neurobiology and Disease. New
York: Oxford University Press; 2009.
14. Margulies, DS, et al. Mapping the functional connectivity of
anterior cingulate cortex. Neuroimage. 2007; 37(2):579–588.
15. McCormick, LM, et al. Anterior cingulate cortex: an MRI-
based parcellation method. Neuroimage. 2006; 32(3):1167–
1175.
16. Forman, SD, et al. Opiate addicts lack error-dependent
activation of rostral anterior cingulate. Biol Psychiatry. 2004;
55(5):531–537.
19(3):1233–1239.
18. Carter, CS, et al. Anterior cingulate cortex, error detection,
and the online monitoring of performance. Science. 1998;
280(5364):747–749.
Subgenual Cingulate Cortex (Area 25)
Main Text
Location
• Anterior margin of genu and rostrum of corpus callosum,

including pregenual and subgenual cingulate gyrus
Boundaries
• Portion of cingulate gyrus ventral to genu of corpus

callosum
• Surrounded by insula (area 13), orbitofrontal cortex (area
11), anterior cingulate cortex (areas 24, 32, and 33)
Function
Emotional Salience and Regulation
• Activity correlated with higher intensity of emotional stimuli

• Facilitates inhibition of negative emotions
• Gradient of processing going from emotional content in
posterior portion within anterior cingulate cortex to salience
in anterior portion within anterior cingulate cortex
Moral Judgment
• Activity associated with feelings of guilt for acting counter to
social values
• Activity also associated with anticipated regret of decisions
Valuation
• Socioeconomic value judgments associated with pregenual

and subgenual activity
Social Attachment
• Regulates release of oxytocin from anterior hypothalamus
Mentalizing
• Part of medial prefrontal hub of default mode network that

processes attention to internal stimuli
2 Subregions Based on Structural Connectivity
• Pregenual
Medial prefrontal cortex and frontal pole (area 10)
Anterior midcingulate cortex
• Subgenual
Nucleus accumbens
Amygdala
Hypothalamus
Orbitofrontal cortex (area 11)
Amygdalohypothalamic connections transmitted by
uncinate fasciculus
Coactive Regions
• Orbitofrontal cortex (area 11), frontal pole (area 10),

precuneus (areas 5 and 7), inferior parietal lobule (areas 39
and 40), hypothalamus, amygdala
• Positive, emotion, reward, craving, negative, money, stress,

addiction, anticipation, choice, salience, dopamine,
depression, outcome, decision making

Depression
• Hyperactivity of subgenual anterior cingulate in task-based

fMRI studies
• Hyperconnectivity of subgenual anterior cingulate with
default mode network, positive correlated with length of
depressive episode
• Decreased gray matter volume of left subgenual cingulate in
depressed patients
• Subgenual cingulate has been effective target for deep brain
stimulation in refractory depression
Subgenual portion is more effective than pregenual
cingulate, reflecting more limbic connectivity profile
• Depression exacerbated by proinflammatory cytokines
acting in subgenual cingulate cortex
Image Gallery
Print Images
SUBGENUAL C INGULATE LOC ATION AND
COACTIVATION
Coronal and axial slices show the relative position of

subgenual cingulate cortex, area 25 (data source: WFU
PickAtlas).
maps.
CONNECTIVITY TO SUBGENUAL CINGULATE CORTEX

CONNECTIVITY TO RIGHT SUBGENUAL CINGULATE

Medial surface rendering shows correlation to a seed region
in the right Brodmann area 25.
Superior surface rendering shows correlation to a seed
CONNECTIVITY TO LEFT SUBGENUAL CINGULATE

in the left Brodmann area 25.
Superior surface rendering shows correlation to a seed
region in the left Brodmann area 25.
SUBGENUAL C INGULATE C ORTEX: C EREBELLAR

CONNECTIVITY
Medial surface-rendered map of subgenual cingulate cortex
is shaded in cyan, representing Brodmann cortical
Workbench).
Additional Images
toolbox for MATLAB.
in bilateral Brodmann area 25, as defined by the WFU
25. Image created using BrainNet Viewer software.
to Brodmann area 25. Image was created using BrainNet
Viewer software.
Connectivity is seen to default mode hubs in the medial
prefrontal and posterior cingulate cortex.
region in bilateral Brodmann area 25, as defined by the
Axial slice at the level of the superior cerebellar peduncles,
to Brodmann area 25.
Axial slice at the level of the uncus, averaged from the same
Axial slice at the level of the mammillary bodies, averaged
from the same data, shows functional connectivity to
Brodmann area 25.
Axial slice at the level of the anterior commissure, averaged
from the same data, shows functional connectivity to
Brodmann area 25.
Selected References
1. McMullen, DP. Where to target? The precision medicine
approach to brain stimulation. Biol Psychiatry. 2018;
84(1):e1–e2.
2. Argyelan, M, et al. Subgenual cingulate cortical activity
predicts the efficacy of electroconvulsive therapy. Transl
Psychiatry. 2016; 6:e789.
3. Clark, DL, et al. Intrinsic local beta oscillations in the
subgenual cingulate relate to depressive symptoms in
treatment-resistant depression. Biol Psychiatry. 2016;
80(11):e93–e94.
4. Vergani, F, et al. Anatomic connections of the subgenual
cingulate region. Neurosurgery. 2016; 79(3):465–472.
5. Bratman, GN, et al. Nature experience reduces rumination
and subgenual prefrontal cortex activation. Proc Natl Acad
Sci U S A. 2015; 112(28):8567–8572.
7. Kravitz, DJ, et al. A new neural framework for visuospatial
9. Harrison, NA, et al. Inflammation causes mood changes
through alterations in subgenual cingulate activity and
mesolimbic connectivity. Biol Psychiatry. 2009; 66(5):407–
414.
10. Matthews, S, et al. Inhibition-related activity in subgenual
cingulate is associated with symptom severity in major
depression. Psychiatry Res. 2009; 172(1):1–6.
11. Zahn, R, et al. Subgenual cingulate activity reflects
individual differences in empathic concern. Neurosci Lett.
2009; 457(2):107–110.
12. Zahn, R, et al. The neural basis of human social values:
evidence from functional MRI. Cereb Cortex. 2009;
19(2):276–283.
13. Johansen-Berg, H, et al. Anatomical connectivity of the
subgenual cingulate region targeted with deep brain
stimulation for treatment-resistant depression. Cereb Cortex.
2008; 18(6):1374–1383.
14. Fehr, E, et al. Social neuroeconomics: the neural circuitry of
social preferences. Trends Cogn Sci. 2007; 11(10):419–427.
15. Amodio, DM, et al. Meeting of minds: the medial frontal
cortex and social cognition. Nat Rev Neurosci. 2006;
7(4):268–277.
19(3):1233–1239.
17. Rolls, ET, et al. Activity of primate subgenual cingulate
cortex neurons is related to sleep. J Neurophysiol. 2003;
90(1):134–142.
18. Botteron, KN, et al. Volumetric reduction in left subgenual
prefrontal cortex in early onset depression. Biol Psychiatry.
2002; 51(4):342–344.
19. Hirayasu, Y, et al. Subgenual cingulate cortex volume in
first-episode psychosis. Am J Psychiatry. 1999; 156(7):1091–
1093.
Retrosplenial Cingulate Cortex (Areas
29, 30)
Main Text
Location
• Paramidline posterior to most caudal portion of corpus

callosum (isthmus of cingulate gyrus)
• Ventrolaterally contiguous with parahippocampal cortex
(area 36)
• Area 26 occupies most rostral portion; area 29 occupies mid
portion (within callosal sulcus); area 30 occupies more
caudal portion of retrosplenial cingulate cortex (onto
convexity of cingulate gyrus)
Boundaries
• Dorsal: Posterior cingulate cortex (area 23) along posterior

extension of corpus callosum
• Ventral: Medial confluence of parietooccipital and calcarine
sulci
Function
Visual Perception and Navigation
• Retrosplenial cingulate cortex situated at junction of

calcarine sulcus and parietooccipital sulcus with close
proximity to primary and secondary visual cortex
• Retrosplenial complex (RSC) is strongly activated during
imagery and viewing of scenes and mental navigation
More strongly active in familiar places (may be long-term
memory of places and environments)
Patients with retrosplenial lesions can identify scenes but
cannot use them effectively for navigation; unable to
orient even in familiar places
Encodes head direction and sequences of spatial
locations
Episodic Memory
• Contiguous with entorhinal, parahippocampal cortex (areas

28, 34, 35, and 36) and likely participating in storage and
retrieval of long-term verbal, spatial, and visual memories
Emotional Perception
• Frequently active in functional imaging studies of emotional

processing
Attention to Internal Stimuli
• Active during daydreaming, resting state, attention to

internal stimuli
• Retrosplenium connects default mode network to
hippocampus

• Dorsolateral prefrontal cortex (areas 9 and 46)
• Posterior cingulate cortex (areas 23 and 31)
• Parahippocampal cortex (areas 28, 34, 35, and 36)
• Intraparietal sulcus (areas 5 and 7)
• Claustrum
• Superior temporal sulcus (area 22)
• Hippocampal subiculum
• Anterior and lateral thalamic nuclei
Papez Circuit
• Anterior thalamic nuclei → cingulate gyrus →

parahippocampal cortex → entorhinal cortex → subiculum
→ fornix → mammillothalamic tract → anterior thalamic
nuclei
• Initially thought to process emotional stimuli, more likely
involved in memory
Coactive Regions
• Visual cortex including lingual gyrus and extrastriate visual

cortex (areas 18 and 19)
• Default mode network: Posterior cingulate cortex (areas 23
and 31), inferior parietal lobule (areas 39 and 40), and weak
coactivation with medial prefrontal hub
• Parahippocampal and entorhinal cortex
• Default, readers, recall, episode, photographs, smoking,

remember, craving, verbal, semantic, sex, words, covert, risk
Areas 29-, 30-Associated Disorders
Alzheimer Dementia
• Early metabolic decreases in retrosplenial cortex in mild

cognitive impairment
Spatial Navigation Impairment (Retrosplenial Amnesia)
• Injured patients have difficulty orienting even in familiar

environments
• Midline location makes bilateral injuries more common than
in bilateral entorhinal cortex
Image Gallery
Print Images
RETROSPLENIAL C INGULATE C ORTEX: LOC ATION AND
COACTIVATION
retrosplenial cingulate cortex, area 29 and area 30 (data
RETROSPLENIAL C INGULATE C ORTEX: C ONNEC TIVIT

(RENDERED)
RETROSPLENIAL C INGULATE C ORTEX: C ONNEC TIVIT

(SLICES)
RETROSPLENIAL C ORTEX: LOC ATION AND C EREBELLAR

CONNECTIVITY
Medial surface-rendered map of the retrosplenial cortex is
shaded for areas 26 (pink), 29 (purple), and 30 (purple)
(data source: Connectome Workbench).
Additional Images
toolbox for MATLAB.
toolbox for MATLAB.
Functional connectivity MR image was averaged from 1,016
region in bilateral Brodmann area 29, as defined by WFU
Left lateral surface-rendered view, averaged from the same
Image was created using BrainNet Viewer software. More
connectivity is seen with posterior cingulate cortex than for
area 30.
Image was created using BrainNet Viewer software. More
connectivity is seen with visual cortex than for area 29.
Image created using BrainNet Viewer software. More
connectivity is seen with temporoparietal junction hubs of
default mode network than for area 30.
Image created using BrainNet Viewer software. More
connectivity with visual attentional regions in medial superior
parietal lobule than for area 29.
Axial slice near the superior margin of the lateral ventricles
shows functional connectivity MR, averaged from 1,016
toolbox for MATLAB.
Axial slice shows functional connectivity MR to Brodmann
area 30 near the superior margin of the lateral ventricles.
area 29 at the level of the mid thalami.
area 30 at the level of the mid thalami. Strong connectivity
is seen with lingual gyri and visual cortex.
area 30 at the level of the mammillary bodies, with robust
connectivity to visual cortex.
Selected References
1. Kaboodvand, N, et al. The retrosplenial cortex: a memory
gateway between the cortical default mode network and the
medial temporal lobe. Hum Brain Mapp. 2018; 39(5):2020–
2034.
2. Mao, D, et al. Hippocampus-dependent emergence of
spatial sequence coding in retrosplenial cortex. Proc Natl
Acad Sci U S A. 2018; 115(31):8015–8018.
3. Shine, JP, et al. The human retrosplenial cortex and
thalamus code head direction in a global reference frame. J
Neurosci. 2016; 36(24):6371–6381.
4. Katche, C, et al. Functional integrity of the retrosplenial
cortex is essential for rapid consolidation and recall of fear
memory. Learn Mem. 2013; 20(4):170–173.
5. Katche, C, et al. On the role of retrosplenial cortex in long-
lasting memory storage. Hippocampus. 2013; 23(4):295–302.
6. Auger, SD, et al, Retrosplenial cortex codes for permanent
landmarks. PLoS One 7 8 2012 e43620
7. Kononenko, NL, et al. Presubiculum layer III conveys
retrosplenial input to the medial entorhinal cortex.
Hippocampus. 2012; 22(4):881–895.
9. Kravitz, DJ, et al. A new neural framework for visuospatial
11. Greicius, MD, et al. Resting-state functional connectivity
reflects structural connectivity in the default mode network.
Cereb Cortex. 2009; 19(1):72–78.
12. Vann, SD, et al. What does the retrosplenial cortex do? Nat
Rev Neurosci. 2009; 10(11):792–802.
13. Epstein, RA. Parahippocampal and retrosplenial
contributions to human spatial navigation. Trends Cogn Sci.
2008; 12(10):388–396.
19(3):1233–1239.
15. Maddock, RJ. The retrosplenial cortex and emotion: new
insights from functional neuroimaging of the human brain.
Trends Neurosci. 1999; 22(7):310–316.
Parahippocampal Gyrus (Areas 28, 34,
35, 36)
Main Text
Location
• Areas 28, 34, 35, and 36: Parahippocampal gyrus, extending

lateral and posterior from hippocampus
Area 28 (ventral entorhinal) and area 34 (dorsal
entorhinal): Adjacent to hippocampal subiculum
Area 35 (perirhinal cortex) and area 36 (ectorhinal,
parahippocampal cortex): Occupy lateral
parahippocampal and anterior fusiform gyri
Boundaries
• Entorhinal cortex (areas 28, 34): Comprises anteromedial

parahippocampal gyrus
Separated from hippocampus by hippocampal fissure
Boundary with subiculum at medial margin ventral to
hippocampal fissure
Separated from perirhinal cortex by collateral sulcus
Areas 28 and 34 separated by tentorial notch
Posteriorly contiguous with retrosplenial cingulate
• Perirhinal cortex (area 35): Immediately lateral to entorhinal
cortex
Includes medial bank of collateral sulcus
Bordered by temporal pole (area 38) rostrally
– Anterior margin 2-3 mm anterior to limen insulae at
anterior margin of collateral sulcus (~ 24 mm caudal
to temporal pole)
• Ectorhinal cortex (area 36): Caudal to perirhinal cortex
Overlapping terms: Ectorhinal, postrhinal,
parahippocampal cortex
Includes anterior medial fusiform gyrus
Lateral margin at occipitotemporal sulcus, separating
perirhinal from inferior temporal cortex (area 20)
Bordered by fusiform gyrus (area 37) caudally
Function
Spatial Navigation
• Map of spatial location and trajectory in entorhinal cortex

with grid cells encoding spatial location and path cells
encoding direction
Olfaction
• Primary olfactory cortex located at anterior margin of

entorhinal cortex at level of anterior margin of amygdala
Encoding Visual Scenes
• Parahippocampal place area (PPA) in posterior collateral

sulcus active during perception of scenes
Memory
• Bridge between hippocampus and neocortex for memory

encoding and retrieval
• 2 parallel streams converge on hippocampus
Visual memory: Posterior parahippocampal to medial
entorhinal
Nonvisual memory: Perirhinal to lateral entorhinal
Entorhinal Cortex
• Hippocampus, amygdala, perirhinal, prefrontal cortex,

retrosplenial cingulate cortex (areas 29 and 30)
Perirhinal/Ectorhinal Cortex
• Amygdala, basal ganglia, olfactory, prefrontal cortex,

sensory association, orbitofrontal cortex (area 11)
Coactive Regions
• Perirhinal/entorhinal: Middle and inferior temporal cortex

(areas 20 and 21), temporal pole (area 38), head of
hippocampus
• Posterior parahippocampal: Posterior cingulate cortex (areas
23 and 31), medial prefrontal cortex, inferior parietal lobule
(areas 39 and 40), body of hippocampus
• Autobiographical, concepts, memories, engaged, recall,

sensation, epilepsy, remember, resting state, drugs,
difficulty, knowledge
Area 28, 34-to 36-Associated Disorders
Alzheimer Dementia
• Entorhinal cortex shows greatest atrophy, site of earliest

pathologic changes
Epilepsy (Medial Temporal Sclerosis)
• Variable involvement of hippocampus, amygdala, and

entorhinal/perirhinal cortex
Image Gallery
Print Images
PARAHIPPOC AMPAL GYRUS: LOC ATION AND
COACTIVATION
the parahippocampal gyrus is shown. This quantitative
28, 34, 35, and 36 (data source: SPM Anatomy toolbox).
Coactivation map of Brodmann areas 28, 34, 35, and 36
shows brain regions that reliably activate with the centroid
of voxels lying within areas 28, 34, 35, and 36 in over 4,000
CONNECTIVITY TO BILATERAL AREA 36

CONNECTIVITY TO AREAS 28 AND 34

Correlation to a seed region in the right Brodmann area 34
is shown.
PARAHIPPOC AMPAL GYRUS: LOC ATION AND

CONNECTIVITY
Ventral surface rendering of a cytoarchitectonic map of the
parahippocampal gyrus is shown. This quantitative
parahippocampal gyrus is shown. This quantitative
datasets. This image shows the correlation to seed regions
in bilateral Brodmann areas 28, 34, 35, and 36 as defined
PARAHIPPOCAMPAL GYRUS: SUBREGIONS

Image created with FreeSurfer software provides a left
medial oblique rendered view of the parahippocampal
gyrus. The entorhinal cortex is shown in yellow, the
perirhinal cortex is shown in blue, and the posterior
parahippocampal cortex is shown in red.
Inferior view of the parahippocampal gyrus is shown.
Functional connectivity MR images show the connectivity to
Brodmann areas 28 and 34-36. Ventral rendered views with
the cerebellum removed are shown. This image was
Additional Images
seed region in the right Brodmann area 36, as defined by
the left Brodmann area 36, as defined by the WFU
seed region in the right Brodmann area 35, as defined by
Selected References
1. Gu, Y, et al. A map-like micro-organization of grid cells in
the medial entorhinal cortex. Cell. 2018; 175(3):736. [50.e30].
2. Diehl, GW, et al. Grid and nongrid cells in medial
entorhinal cortex represent spatial location and
environmental features with complementary coding
schemes. Neuron. 2017; 94(1):83–92.e6.
3. Augustinack, JC, et al. Predicting the location of human
perirhinal cortex, Brodmann’s area 35, from MRI.
Neuroimage. 2013; 64:32–42.
4. Jacobs, J, et al. Direct recordings of grid-like neuronal
activity in human spatial navigation. Nat Neurosci. 2013;
16(9):1188–1190.
5. Libby, LA, et al. Differential connectivity of perirhinal and
parahippocampal cortices within human hippocampal
subregions revealed by high-resolution functional imaging. J
Neurosci. 2012; 32(19):6550–6560.
8. Nasr, S, et al. Scene-selective cortical regions in human and
nonhuman primates. J Neurosci. 2011; 31(39):13771–13785.
9. Jacobs, J, et al. A sense of direction in human entorhinal
cortex. Proc Natl Acad Sci U S A. 2010; 107(14):6487–6492.
10. Fischl, B, et al. Predicting the location of entorhinal cortex
from MRI. Neuroimage. 2009; 47(1):8–17.
11. Kahn, I, et al. Distinct cortical anatomy linked to subregions
of the medial temporal lobe revealed by intrinsic functional
connectivity. J Neurophysiol. 2008; 100(1):129–139.
12. Amunts, K, et al. Cytoarchitectonic mapping of the human
amygdala, hippocampal region and entorhinal cortex:
intersubject variability and probability maps. Anat Embryol
(Berl). 2005; 210(5-6):343–352.
13. Hafting, T, et al. Microstructure of a spatial map in the
entorhinal cortex. Nature. 2005; 436(7052):801–806.
14. Fyhn, M, et al. Spatial representation in the entorhinal
cortex. Science. 2004; 305(5688):1258–1264.
15. Pruessner, JC, et al. Volumetry of temporopolar, perirhinal,
entorhinal and parahippocampal cortex from high-
resolution MR images: considering the variability of the
collateral sulcus. Cereb Cortex. 2002; 12(12):1342–1353.
16. Brown, MW, et al. Recognition memory: what are the roles
of the perirhinal cortex and hippocampus? Nat Rev
Neurosci. 2001; 2(1):51–61.
17. Frank, LM, et al. Trajectory encoding in the hippocampus
and entorhinal cortex. Neuron. 2000; 27(1):169–178.
18. Epstein, R, et al. The parahippocampal place area:
recognition, navigation, or encoding? Neuron. 1999;
23(1):115–125.
19. Insausti, R, et al. MR volumetric analysis of the human
entorhinal, perirhinal, and temporopolar cortices. AJNR Am
J Neuroradiol. 1998; 19(4):659–671.
Fusiform Gyrus (Area 37)
Main Text
Location
• Bridges temporal and occipital lobes anterior to inferior

occipital gyrus, anterolateral to lingual gyrus, medial to
parahippocampal gyrus, and inferolateral to inferior
temporal gyrus
Boundaries
• Collateral sulcus separates fusiform gyrus from

parahippocampal gyrus (area 35)
• Occipitotemporal sulcus separates fusiform gyrus from
inferior temporal gyrus (area 20)
• Marginated anteriorly by temporal horn, collateral sulcus,
and amygdala
• Surrounded by temporal cortex (areas 20, 21, and 22), visual
cortex (area 19), and inferior parietal lobule (area 39)
Cytoarchitectonic Regions
• hOC4v: Extrastriate visual cortex (V4)

• FG1: Anterior to hOC4v on medial fusiform gyrus
• FG2: Anterior to hOC4v on lateral fusiform gyrus, likely
includes fusiform face area (FFA)
Function
Higher Order Visual Processing
• Part of "what" pathway

• Part of extrastriate visual cortex that processes more
complex feature abstraction from visual inputs
• Extrastriate visual area hOC4v involves most posterior
portion of fusiform gyrus
hOC4v participates in perception of color in visual
stimuli
Face and Body Processing
• FFA contains neurons sensitive to faces

Located on lateral bank of mid to posterior fusiform
gyrus
• Adjacent area active when individual views human body or
analogous form (extrastriate body area)
• Other facial processing regions exist in occipital face area
(inferior occipital gyrus), superior temporal sulcus, and
anterior temporal pole
• FFA active not only to faces but other specialized objects
(e.g., cars) for subjects with categorical expertise
• Face-sensitive neurons functionally distinct from adjacent
color-sensitive neurons
Visual Word Form Area
• Basal temporal language area (visual word form area) has

been proposed in mid/posterior left fusiform gyrus
• Area is not specific to language but may be involved in letter
and word recognition and other high-order visual
discrimination tasks
• Fusiform gyrus likely functions for local shape processing of
letters whereas lingual gyrus is associated with global shape
processing
Face Processing Network
• Occipital face area, superior temporal sulcus, anterior

temporal pole (area 38), amygdala
Visual Network
• Extrastriate visual cortex, visual attentional regions in

superior parietal lobule (areas 5 and 7)
Coactive Regions
• Extrastriate visual cortex, middle temporal (MT),

posteromedial superior temporal lobule (visual attention),
posterior insula (area 13)
• Lexical, face, orthographic, facial, words, semantic, picture,

reading, houses, expressions, photographs, visual

Prosopagnosia
• Although FFA lesions are associated with prosopagnosia,

dysfunction at other sites with intact FFA can still produce
prosopagnosia
• Typically results from bilateral FFA lesions
• Face perception network also includes inferior occipital,
superior temporal sulcus, amygdalar, and temporal pole
regions
Autism
• Hypoactivation and decreased functional connectivity of

FFA
Image Gallery
Print Images
COACTIVATION OF FUSIFORM GYRUS (AREA 37)
Axial and coronal slices show the relative position of
fusiform gyrus area 37 (data source: WFU PickAtlas).
maps.
CONNECTIVITY TO FUSIFORM GYRUS (AREA 37)

Cerebellar surface rendering shows correlation to a seed
region in the bilateral Brodmann area 37.
CONNECTIVITY TO BILATERAL FUSIFORM GYRUS

PROBABILISTIC MAP OF AREA 37

Ventral surface rendering of a cytoarchitectonic map of
fusiform gyrus (area 37) is shown.
Axial slice at the level of the superior cerebellar peduncles
shows functional connectivity MR, averaged from 1,016
Brodmann area 37 as defined by the WFU PickAtlas toolbox
for MATLAB.
FUSIFORM GYRUS (AREA 37)

Medial surface-rendered map of fusiform gyrus is shaded in
green, representing Brodmann cortical parcellation scheme
for area 37 (data source: Connectome Workbench).
Lateral surface-rendered map of fusiform gyrus is shown.
Ventral surface-rendered map of fusiform gyrus is shown.
Additional Images
Medial surface rendering of a cytoarchitectonic map of
fusiform gyrus is shown. This quantitative probabilistic map
to cellular properties unique to area 37 (data source: SPM
Anatomy toolbox).
Lateral surface rendering of a cytoarchitectonic map of
fusiform gyrus is shown. This quantitative probabilistic map
to cellular properties unique to area 37 (data source: SPM
Anatomy toolbox).
Axial slice at the level of the midtectum shows functional
connectivity MR, averaged from 1,016 typically developing
volunteers (ages 18-30) from the 1,000 Functional
Connectomes and ADHD-200 datasets. The image shows
correlation to a seed region in bilateral Brodmann area 37,
(fusiform gyrus). Image was created using BrainNet Viewer
software.
software.
to Brodmann area 37 (fusiform gyrus). Image was created
software.
37 (fusiform gyrus). Image created using BrainNet Viewer
software.
toolbox for MATLAB.
Selected References
1. Weiner, KS, et al. On object selectivity and the anatomy of
the human fusiform gyrus. Neuroimage. 2018; 173:604–609.
2. Lorenz, S, et al. Two new cytoarchitectonic areas on the
human mid-fusiform gyrus. Cereb Cortex. 2017; 27(1):373–
385.
3. Schalk, G, et al. Facephenes and rainbows: causal evidence
for functional and anatomical specificity of face and color
processing in the human brain. Proc Natl Acad Sci U S A.
2017; 114(46):12285–12290.
4. Caspers, J, et al. Cytoarchitectonical analysis and
probabilistic mapping of two extrastriate areas of the
human posterior fusiform gyrus. Brain Struct Funct. 2013;
218(2):511–526.
5. McGugin, RW, et al. High-resolution imaging of expertise
reveals reliable object selectivity in the fusiform face area
related to perceptual performance. Proc Natl Acad Sci U S A.
2012; 109(42):17063–17068.
8. Nestor, A, et al. Unraveling the distributed neural code of
facial identity through spatiotemporal pattern analysis. Proc
Natl Acad Sci U S A. 2011; 108(24):9998–10003.
9. Saygin, ZM, et al. Anatomical connectivity patterns predict
face selectivity in the fusiform gyrus. Nat Neurosci. 2011;
15(2):321–327.
10. van Kooten, IA, et al. Neurons in the fusiform gyrus are
fewer and smaller in autism. Brain. 2008; 131(Pt 4):987–999.
11. Taylor, JC, et al. Functional MRI analysis of body and body
part representations in the extrastriate and fusiform body
areas. J Neurophysiol. 2007; 98(3):1626–1633.
12. Peelen, MV, et al. Selectivity for the human body in the
fusiform gyrus. J Neurophysiol. 2005; 93(1):603–608.
19(3):1233–1239.
14. McCandliss, BD, et al. The visual word form area: expertise
for reading in the fusiform gyrus. Trends Cogn Sci. 2003;
7(7):293–299.
15. Price, CJ, et al. The myth of the visual word form area.
NeuroImage. 2003; 19(3):473–481.
16. Gauthier, I, et al. Activation of the middle fusiform ‘face
area’ increases with expertise in recognizing novel objects.
Nat Neurosci. 1999; 2(6):568–573.
17. McCarthy, G, et al. Face-specific processing in the human
fusiform gyrus. J Cogn Neurosci. 1997; 9(5):605–610.
Temporal Pole (Area 38)
Main Text
Location
• Most rostral portion of temporal lobes

• Present only in humans and nonhuman primates
Boundaries
• Rostral: Perirhinal cortex

• Lateral: Amygdala
Function
Multimodal Sensory/Emotional Integration
• Temporal pole combines multimodal sensory

representations with emotive input from orbitofrontal cortex
and amygdala
Face Recognition and Social Processing
• Facial recognition regions in fusiform face area, inferior

temporal, superior temporal sulcus, and temporal pole
• Hypothesized that temporal pole adds emotive information
to facial recognition
Theory of Mind
• Temporal pole activation across broad range of studies

involved in mentalizing, imagining mental states of others
Memory
• Right temporal pole more associated with emotion and

social memory, left temporal pole with semantic memory
and facial naming
• Activation can be associated with false memories
Complex Object Naming
• Represented bilaterally in temporal poles
Orbitofrontal Cortex and Amygdala
• Mediated by uncinate fasciculus
Basal Forebrain and Hypothalamus
• Similar to other paralimbic regions
Multimodal Sensory Cortex
• Reciprocal connections to auditory (areas 41 and 42), visual

(area 17, 18, and 19), somatosensory (areas 1, 2, and 3), and
olfactory association cortices
Insula
• Particularly ventral insula (area 13)

• Particularly ventral insula (area 13)
Coactive Regions
• Medial temporal lobe, superior temporal gyrus (area 22),

superior temporal sulcus, lateral inferior frontal gyrus (areas
44, 45, and 47), superior parietal cortex (areas 5 and 7),
extrastriate visual cortex
• Functional connectivity and task-based fMRI are often
unreliable in temporal poles because of susceptibility artifact
• Self-referential, scenarios, story, memories, conceptual, self,

thinking, theory of mind, person, perspective, concepts,
videos, social, retrieval, attribution

Traumatic Brain Injury
• Temporal poles commonly contused in closed head injury
Semantic Dementia
• Atrophy and hypometabolism of ventral rostral temporal

lobe, especially temporal poles, usually asymmetric
• Right anterior temporal involvement most associated with
socioemotional dysregulation
Klüver-Bucy Syndrome
• Diminished fear, hyperorality, hypersexuality, blunted affect

• Can result from bilateral amygdala, orbitofrontal, and
temporal pole cortex lesions
Neurosurgery
• Anterior temporal poles often removed in temporal

lobectomy, injured by retraction in aneurysm clipping
Image Gallery
Print Images
TEMPORAL POLE: LOCATION AND COACTIVATION
Coronal and axial slices show the relative position of
temporal pole area 38 (data source: WFU PickAtlas).
database. This image is the average of left and right
coactivation maps.
CONNECTIVITY TO RIGHT TEMPORAL POLE

Lateral surface rendering shows correlation to a seed
in the right Brodmann area 38.
CONNECTIVITY TO LEFT TEMPORAL POLE

Lateral surface rendering shows correlation to a seed
region in the left Brodmann area 38.
in the left Brodmann area 38.
CONNECTIVITY TO BILATERAL TEMPORAL POLE

TEMPORAL POLE: LOCATION

Frontal surface-rendered map of the temporal pole is
Workbench).
Medial surface-rendered map of the temporal pole is
shown.
Ventral surface-rendered map of the temporal pole is
shown.
Additional Images
toolbox for MATLAB.
Functional connectivity MR image was averaged from 1,016
Right lateral rendered view, averaged from the same data,
shows functional connectivity to Brodmann area 38
(temporal pole). This image was created using BrainNet
Viewer software.
Dorsal rendered view, averaged from the same data,
Viewer software.
Ventral rendered view with the cerebellum removed,
to Brodmann area 38 (temporal pole). This image was
Medial rendered view, averaged from the same data,
Viewer software.
Frontal rendered view, averaged from the same data,
Viewer software.
Axial slice shows a functional connectivity MR, averaged
bilateral Brodmann area 38, as defined by the WFU
PickAtlas toolbox for MATLAB. Slice is positioned at the
level of the uncus.
Functional connectivity MR to Brodmann area 38 is shown in
a single axial slice at the level of the superior cerebellar
peduncles.
Lateral surface-rendered map of the temporal pole is
Workbench).
Selected References
1. Abel, TJ, et al. Role of the temporal pole in temporal lobe
epilepsy seizure networks: an intracranial electrode
investigation. J Neurosurg. 2018; 129(1):165–173.
2. Collins, JA, et al. Focal temporal pole atrophy and network
degeneration in semantic variant primary progressive
aphasia. Brain. 2017; 140(2):457–471.
3. Chadwick, MJ, et al. Semantic representations in the
temporal pole predict false memories. Proc Natl Acad Sci U S
A. 2016; 113(36):10180–10185.
4. Sajjadi, SA, et al. Diffusion tensor magnetic resonance
imaging for single subject diagnosis in neurodegenerative
diseases. Brain. 2013; 136(Pt 7):2253–2261.
6. Acosta-Cabronero, J, et al. Atrophy, hypometabolism and
white matter abnormalities in semantic dementia tell a
coherent story. Brain. 2011; 134(Pt 7):2025–2035.
7. Binder, JR, et al. Mapping anterior temporal lobe language
areas with fMRI: a multicenter normative study.
Neuroimage. 2011; 54(2):1465–1475.
9. Tsapkini, K, et al. The function of the left anterior temporal
pole: evidence from acute stroke and infarct volume. Brain.
2011; 134(Pt 10):3094–3105.
10. Blaizot, X, et al. The human parahippocampal region: I.
Temporal pole cytoarchitectonic and MRI correlation. Cereb
Cortex. 2010; 20(9):2198–2212.
11. Ross, LA, et al. Social cognition and the anterior temporal
lobes. Neuroimage. 2010; 49(4):3452–3462.
12. Simmons, WK, et al. The selectivity and functional
connectivity of the anterior temporal lobes. Cereb Cortex.
2010; 20(4):813–825.
13. Seeley, WW, et al. Neurodegenerative diseases target large-
scale human brain networks. Neuron. 2009; 62(1):42–52.
14. Olson, IR, et al. The enigmatic temporal pole: a review of
findings on social and emotional processing. Brain. 2007;
130(Pt 7):1718–1731.
19(3):1233–1239.
Inferior Parietal Lobule (Areas 39, 40)
Main Text
Location
• Area 39 (angular gyrus)

Caudal inferior parietal lobule
• Area 40 (supramarginal gyrus)
Rostral inferior parietal lobule
• Inferior parietal lobule contains 7 distinct cytoarchitectonic
regions
Boundaries
• Area 39
Caudal: Area 19 (parietooccipital sulcus)
Rostral: Area 40
Dorsal: Intraparietal sulcus
Angular gyrus is cortex surrounding caudal superior
temporal sulcus (cSTS)
– cSTS has 3 branches in inferior parietal lobule:
Anterior, central, and posterior branch
• Area 40
Caudal: Area 39
Rostral: Postcentral sulcus
Dorsal: Intraparietal sulcus
Ventral: Caudal aspect of circular sulcus of insula
Function
Reading
• Area 39 maps visual and auditory inputs onto semantic

representations
Angular gyrus is core hub of reading network, especially
cortex between central and posterior branches of cSTS
• Area 40 participates in creating representations of word
sounds
Mental Arithmetic
• Area 39 participates especially when fact retrieval is required
Action Awareness
• Right area 39 processes discrepancies between intended and

actual actions
Memory for Auditory Pitch
• Left area 40 direct current stimulation disrupts pitch

memory
Auditory Attention
• Area 40 (lateral intraparietal sulcus) processes attention to

auditory stimuli
Area 39
• Connections to Broca area and Wernicke area via arcuate

fasciculus
• Extensive interconnectivity with posterior temporal lobe
Area 40
• Connections to ventral premotor cortex
Coactive Regions
• Area 39
Default mode network (posterior cingulate, inferior
temporal, medial prefrontal)
• Area 40
Ventral attention network (inferior frontal/premotor,
dorsolateral prefrontal, middle temporal, anterior
cingulate, superior insula)
• Thinking, stop, awareness, no go, word, perspective,

retrieved, fluency, default, recollection, game, inhibition,
automatic, semantic, prosodic, story

Hemispatial Neglect
• Commonly seen with injury to right hemispheric ventral

attention network
Dyslexia
• Functional disconnection of angular gyrus from occipital

• Functional disconnection of angular gyrus from occipital
and temporal language regions hypothesized
Angular Gyrus Syndrome
• Sensory aphasia, alexia with agraphia, finger agnosia,

constructional apraxia (Gerstmann syndrome) with left
angular gyrus injury
Image Gallery
Print Images
INFERIOR PARIETAL LOBULE: LOC ATION AND
COACTIVATION
angular gyrus area 39 and supramarginal gyrus area 40
(data source: WFU PickAtlas).
from the NeuroSynth database. This image is the average
of left and right coactivation maps.
AREA 39: FUNCTIONAL CONNECTIVITY

39 is shown.
AREA 40: FUNCTIONAL CONNECTIVITY

40 is shown.
LOCATION: ANGULAR AND SUPRAMARGINAL GYRI

Lateral surface rendering of a cytoarchitectonic map of the
angular gyrus is shown. This quantitative probabilistic map
to cellular properties that are unique to area 39 (data
Lateral surface rendering of a cytoarchitectonic map of the
supramarginal gyrus is shown representing area 40.
Lateral surface map of the angular gyrus is shaded in burnt
orange, representing Brodmann cortical parcellation scheme
for area 39 (data source: Connectome Workbench).
LOCATION: AREAS 39 AND 40

Lateral surface map of the supramarginal gyrus is shaded in
red, representing Brodmann cortical parcellation scheme for
area 40 (data source: Connectome Workbench).
Posterior surface rendering of a cytoarchitectonic map of
the angular gyrus is shown. This quantitative probabilistic
map was derived from postmortem human brains and is
specific to cellular properties that are unique to area 39
Sagittal sections of an inferior parietal lobule map show a
Brodmann cortical parcellation scheme for areas 39 and 40
(data source: WFU PickAtlas).
Additional Images
supramarginal gyrus is shown. This quantitative probabilistic
map was derived from postmortem human brains and is
specific to cellular properties that are unique to area 40
angular gyrus is shown. This quantitative probabilistic map
to cellular properties that are unique to area 39 (data
using BrainNet Viewer software. Area 40 includes the
lateral margin of the intraparietal sulcus and shows
connectivity with the dorsal attention network.
from 1,000 Functional Connectomes and ADHD-200
using BrainNet Viewer software. Area 39 coincides with the
temporoparietal junction hub of the default mode network
with connectivity to medial prefrontal and posterior cingulate
areas.
Selected References
1. Igelström, KM, et al. The inferior parietal lobule and
temporoparietal junction: a network perspective.
Neuropsychologia. 2017; 105:70–83.
2. Krall, SC, et al. The role of the right temporoparietal
junction in attention and social interaction as revealed by
ALE meta-analysis. Brain Struct Funct. 2015; 220(2):587–
604.
3. Strombach, T, et al. Social discounting involves modulation
of neural value signals by temporoparietal junction. Proc
Natl Acad Sci U S A. 2015; 112(5):1619–1624.
4. Caspers, S, et al. Organization of the human inferior
parietal lobule based on receptor architectonics. Cereb
Cortex. 2013; 23(3):615–628.
5. Segal, E, et al. Functional activation during reading in
relation to the sulci of the angular gyrus region. Eur J
Neurosci. 2013; 38(5):2793–2801.
6. Segal, E, et al. The morphology and variability of the caudal
rami of the superior temporal sulcus. Eur J Neurosci. 2012;
36(1):2035–2053.
9. Uddin, LQ, et al. Dissociable connectivity within human
angular gyrus and intraparietal sulcus: evidence from
functional and structural connectivity. Cereb Cortex. 2010;
20(11):2636–2646.
10. Grabner, RH, et al. To retrieve or to calculate? Left angular
gyrus mediates the retrieval of arithmetic facts during
problem solving. Neuropsychologia. 2009; 47(2):604–608.
11. Stoeckel, C, et al. Supramarginal gyrus involvement in visual
word recognition. Cortex. 2009; 45(9):1091–1096.
12. Caspers, S, et al. The human inferior parietal lobule in
stereotaxic space. Brain Struct Funct. 2008; 212(6):481–495.
13. Farrer, C, et al. The angular gyrus computes action
awareness representations. Cereb Cortex. 2008; 18(2):254–
261.
14. Caspers, S, et al. The human inferior parietal cortex:
cytoarchitectonic parcellation and interindividual
variability. Neuroimage. 2006; 33(2):430–448.
19(3):1233–1239.
16. Horwitz, B, et al. Functional connectivity of the angular
gyrus in normal reading and dyslexia. Proc Natl Acad Sci U S
A. 1998; 95(15):8939–8944.
Primary Auditory and Auditory
Association Cortex (Areas 41, 42)
Main Text
Location
• Transverse temporal gyrus of Heschl: Primary auditory

cortex (area 41)
Located in depth of sylvian fissure along mid superior
temporal gyrus
• Area 42: Unimodal auditory association cortex
Contained within planum temporale, lateral to area 41
Planum temporale extends more dorsally in right
hemisphere than left toward angular gyrus
– Also includes portions of area 22, overlapping with
Wernicke area caudally
Located medial to area 22 (superior temporal gyrus)
Boundaries
• Area 41: Lateral to 1st temporal sulcus (rostrally) and

Heschl sulcus (caudally)
• Area 42: Separated from area 41 by Heschl sulcus
Separated from area 22 by superolateral margin of
superior temporal gyrus
• Surrounded by insula and parainsula areas (areas 13 and
43), superior temporal gyrus (area 22), and supramarginal
gyrus (area 40)
Function
Auditory Perception
• 3 cytoarchitectonic subregions within area 41

• Primary auditory cortex occupies medial 2/3 of Heschl gyrus
• At least 2 tonotopic maps extend across primary auditory
cortex with lower frequencies lateral, high frequencies
medial
Additional tonotopic map in planum temporale, possibly
additional maps in auditory association cortex, similar to
retinotopic maps in visual cortex
• Higher order auditory perception includes combinations of
frequencies, timbre, and feature detection
Input
• Medial geniculate nucleus of thalamus

Auditory input: CNVIII nucleus → superior olive →
inferior colliculus → medial geniculate nucleus →
primary auditory cortex
Output and Reciprocal Connections
• Auditory association cortex: Superior and middle temporal

gyri (areas 21 and 22)
• Caudal insula: Multimodal sensory integration
• Lateral intraparietal sulcus (area 40): Auditory attention
Coactive Regions

• Posterior cingulate cortex (areas 23 and 31)
• Medial geniculate nucleus of thalamus
• Sensorimotor cortex (areas 1, 2, 3, and 4)
• Occipital lingual gyrus
• Lateral cerebellar hemispheres
• Auditory, audiovisual, sound, speech, pitch, tones, vocal,

noise, ear, integration, noise, psychophysical

Cortical Hearing Loss
• Especially with bilateral auditory cortex injury

• Tonotopic map reorganization can occur with auditory
trauma
Cochlear and Peripheral Hearing loss
• Visual stimuli can activate auditory cortex in deaf patients
Tinnitus
• Reorganization of tonotopic map can predispose to noise-

induced tinnitus
Increased spontaneous firing rates for neurons in
auditory cortex
Pathophysiology consistent with auditory analogue of
phantom limb pain
Visual Blindness
• Auditory cortex and tonotopic map undergoes expansion

following visual loss
Image Gallery
Print Images
AUDITORY CORTEX: LOCATION AND COACTIVATION
auditory cortex is shown. This quantitative probabilistic map

CONNECTIVITY TO AUDITORY CORTEX

Cerebellar surface rendering shows the correlation to a
seed region in the bilateral Brodmann area 42.
CONNECTIVITY TO PRIMARY AUDITORY CORTEX

LOCATION OF AUDITORY CORTEX

Axial section of the auditory cortex is displayed at the level
of the inferior insula, including Brodmann cortical
parcellation scheme for areas 41 and 42 (data source:
WFU PickAtlas).
Axial section of the auditory cortex is displayed at the level
of the superior insula, including Brodmann cortical
WFU PickAtlas).
Coronal section of the auditory cortex is displayed at the
level of the middle cerebellar peduncles, including Brodmann
cortical parcellation scheme for areas 41 and 42 (data
LOCATION OF AUDITORY CORTEX

Coronal section of the auditory cortex is displayed at the
level of the hippocampi and thalamus, including Brodmann
cortical parcellation scheme for areas 41 and 42 (data
source: WFU PickAtlas). Inputs to primary auditory cortex
arise from the medial geniculate nuclei of the thalamus.
Sagittal section of the auditory cortex is displayed at the
lateral margin of area 41, including Brodmann cortical
WFU PickAtlas). Heschl gyrus lies in the mid to posterior
portion of the medial superior temporal gyrus, medial to
planum temporale.
Lateral surface map of the primary auditory and auditory
association cortex represents Brodmann cortical
Additional Images
toolbox for MATLAB.
toolbox for MATLAB.
Functional connectivity MR is shown, averaged from 1,016
toolbox for MATLAB. Image was created using BrainNet
Viewer software. Note the strong correlation with the
posterior insula just medial to area 41.
Functional connectivity MR is shown, averaged from 1,016
toolbox for MATLAB. Image was created using BrainNet
Viewer software. Note the strong correlation with superior
temporal gyrus (auditory association cortex).
toolbox for MATLAB.
toolbox for MATLAB.
Selected References
1. Allen, EJ, et al. Encoding of natural timbre dimensions in
human auditory cortex. Neuroimage. 2018; 166:60–70.
2. Allen, EJ, et al. Representations of pitch and timbre
variation in human auditory cortex. J Neurosci. 2017;
37(5):1284–1293.
3. Kato, HK, et al. Network-level control of frequency tuning
in auditory cortex. Neuron. 2017; 95(2):412. [23.e4].
4. Tang, C, et al. Intonational speech prosody encoding in the
human auditory cortex. Science. 2017; 357(6353):797–801.
5. Lakatos, P, et al. Global dynamics of selective attention and
its lapses in primary auditory cortex. Nat Neurosci. 2016;
19(12):1707–1717.
6. De Martino, F, et al. Frequency preference and attention
effects across cortical depths in the human primary
auditory cortex. Proc Natl Acad Sci U S A. 2015;
112(52):16036–16041.
7. Prigge, MD, et al. Longitudinal Heschl’s gyrus growth
during childhood and adolescence in typical development
and autism. Autism Res. 2013; 6(2):78–90.
8. Langers, DR, et al. Mapping the tonotopic organization in
human auditory cortex with minimally salient acoustic
stimulation. Cereb Cortex. 2012; 22(9):2024–2038.
9. Roberts, LE, et al. Ringing ears: the neuroscience of
tinnitus. J Neurosci. 2010; 30(45):14972–14979.
10. Woods, DL, et al, Functional maps of human auditory
cortex: effects of acoustic features and attention. PLoS One 4
4 2009 e5183
11. Upadhyay, J, et al. Function and connectivity in human
primary auditory cortex: a combined fMRI and DTI study at
3 Tesla. Cereb Cortex. 2007; 17(10):2420–2432.
12. Dorsaint-Pierre, R, et al. Asymmetries of the planum
temporale and Heschl’s gyrus: relationship to language
lateralization. Brain. 2006; 129(Pt 5):1164–1176.
13. Formisano, E, et al. Mirror-symmetric tonotopic maps in
human primary auditory cortex. Neuron. 2003; 40(4):859–
869.
14. Finney, EM, et al. Visual stimuli activate auditory cortex in
the deaf. Nat Neurosci. 2001; 4(12):1171–1173.
15. Morosan, P, et al. Human primary auditory cortex:
cytoarchitectonic subdivisions and mapping into a spatial
reference system. Neuroimage. 2001; 13(4):684–701.
16. Shapleske, J, et al. The planum temporale: a systematic,
quantitative review of its structural, functional and clinical
significance. Brain Res Brain Res Rev. 1999; 29(1):26–49.
17. Mühlnickel, W, et al. Reorganization of auditory cortex in
tinnitus. Proc Natl Acad Sci U S A. 1998; 95(17):10340–
10343.
18. Romani, GL, et al. Tonotopic organization of the human
auditory cortex. Science. 1982; 216(4552):1339–1340.
Inferior Frontal Gyrus (Areas 44, 45,
47)
Main Text
Location
• Area 44 (pars opercularis)

Most caudal inferior frontal gyrus (IFG), rostral to
premotor cortex (area 6)
• Area 45 (pars triangularis)
Dorsal to area 47, rostral to area 44
• Area 47 (pars orbitalis)
Most rostral/ventral IFG, bordering with orbitofrontal
cortex (area 11)
Boundaries
• Classic definitions based on orbital, triangular, and

opercular gyri, but more precise probabilistic maps now
available
Function
Expressive Language (Broca Area)
• Phonological processing more dorsal (areas 44 and 45),

semantic processing more ventral in IFG (areas 45 and 47)
Response Inhibition
• Right IFG recruited for important cues in stop-signal

paradigms
Attention
• Right IFG part of ventral attention network; injury can cause

hemispatial neglect
Other Hypothesized Roles
• Working memory, empathy, motor imagery (more posterior)
Cytoarchitectonic Similarity
• Areas 44, 45 show high similarity of

neurotransmitters/modulators, differentiated from area 47
Reciprocal Connections With Language Regions (Left > Right)
• Local connections: Lateral premotor area (area 6) adjacent

to area 44, area 8, area 9
Activation often blurred between area 44 and area 6
• Dorsal pathway: Arcuate fasciculus to superior and middle
temporal gyri (areas 21 and 22) and inferior parietal lobule
(areas 39 and 40)
Largest fiber pathway in humans
• Ventral pathway: Extreme capsule to superior and middle
temporal gyri (areas 21 and 22)
• Frontal aslant tract: Connects IFG to anterior cingulate
cortex (areas 24, 32, and 33) and presupplementary motor
area (area 6)
Atrophic in primary progressive aphasia
Homotopic Left/Right Connectivity
• Strong callosal connections between left/right homologues
Local Connections
• Connections with insula (area 13), temporal pole (area 38),

and medial temporal lobe mediated by uncinate fasciculus
Coactive Regions
• Orbitofrontal cortex (area 11), superior/middle temporal gyri

(areas 21 and 22), angular gyrus (area 39), supramarginal
gyrus (area 40), lateral premotor cortex (area 6), anterior
cingulate cortex (areas 24, 32, and 33)
• Left hemisphere: Word, language, semantic, verb, sentence,

lexical, readers, phonological
• Right hemisphere: Pain, syllable, skin, stop, shock,
numerical, empathy, noxious

Broca Aphasia
• Poor verbal fluency with relatively intact language

comprehension
Image Gallery
Print Images
INFERIOR FRONTAL GYRUS: LOC ATION AND
COACTIVATION
Cytoarchitectonic map of posterior inferior frontal gyrus is

shown. This quantitative probabilistic map was derived from
postmortem human brains and is specific to cellular
properties unique to areas 44 and 45 (data source: SPM
Anatomy toolbox).
CONNECTIVITY TO INFERIOR FRONTAL GYRUS

Correlation to a seed region in the left Brodmann area 47 is
shown.
CONNECTIVITY TO INFERIOR FRONTAL GYRUS

in bilateral Brodmann areas 44, 45, and 47 as defined by
BRODMANN AREAS 44, 45, 47

Lateral surface map of the inferior frontal gyrus is shaded in
purple, representing Brodmann cortical parcellation scheme
for pars opercularis area 44 (data source: Connectome
Workbench).
violet, representing Brodmann cortical parcellation scheme
for pars triangularis area 45.
orange, representing Brodmann cortical parcellation scheme
for pars orbitalis area 47.
Lateral surface rendering of a cytoarchitectonic map of
Broca area is shown. This quantitative probabilistic map
Axial section of the posterior inferior frontal gyrus is
displayed, including Brodmann cortical parcellation scheme
for areas 44 and 45 (data source: WFU PickAtlas).
Axial section of the pars orbitalis is displayed, including
Additional Images
PickAtlas toolbox for MATLAB. Greater connectivity is seen
with angular gyrus (area 39) than for other inferior frontal
gyrus regions.
in bilateral Brodmann area 45 as defined by WFU PickAtlas
toolbox for MATLAB. Connectivity is shown both with
language regions (Wernicke area) as well as ventral
attention network (anterior cingulate and anterior insula).
in bilateral Brodmann area 47 as defined by WFU PickAtlas
toolbox for MATLAB. Connectivity is higher to orbitofrontal
cortex than for other regions in the inferior frontal gyrus.
Selected References
1. Zilles, Karl, et al, Cytoarchitectonic and
receptorarchitectonic organization in Broca’s region and
surrounding cortexPetkov C, et al, eds. Current Opinion in
Behavioral Sciences vol. 21 2018 93–105.
https://www.sciencedirect.com/science/article/pii/S23521546173013
Published June 2018. Accessed October 2019.
2. Jakobsen, E, et al. Automated individual-level parcellation
of Broca’s region based on functional connectivity.
Neuroimage. 2018; 170:41–53.
3. Catani, M, et al. A novel frontal pathway underlies verbal
fluency in primary progressive aphasia. Brain. 2013; 136(Pt
8):2619–2628.
4. Amunts, K, et al. Architecture and organizational
principles of Broca’s region. Trends Cogn Sci. 2012;
16(8):418–426.
7. Tyler, LK, et al. Left inferior frontal cortex and syntax:
function, structure and behaviour in patients with left
hemisphere damage. Brain. 2011; 134(Pt 2):415–431.
8. Ford, A, et al. Structural connectivity of Broca’s area and
medial frontal cortex. Neuroimage. 2010; 52(4):1230–1237.
9. Friederici, AD. Pathways to language: fiber tracts in the
human brain. Trends Cogn Sci. 2009; 13(4):175–181.
10. Kilner, JM, et al. Evidence of mirror neurons in human
inferior frontal gyrus. J Neurosci. 2009; 29(32):10153–10159.
11. Shamay-Tsoory, SG, et al. Two systems for empathy: a
double dissociation between emotional and cognitive
empathy in inferior frontal gyrus versus ventromedial
prefrontal lesions. Brain. 2009; 132(Pt 3):617–627.
12. Costafreda, SG, et al. A systematic review and quantitative
appraisal of fMRI studies of verbal fluency: role of the left
inferior frontal gyrus. Hum Brain Mapp. 2006; 27(10):799–
810.
13. Amunts, K, et al. Analysis of neural mechanisms underlying
verbal fluency in cytoarchitectonically defined stereotaxic
space--the roles of Brodmann areas 44 and 45. Neuroimage.
2004; 22(1):42–56.
14. Kier, EL, et al. MR imaging of the temporal stem: anatomic
dissection tractography of the uncinate fasciculus, inferior
occipitofrontal fasciculus, and Meyer’s loop of the optic
radiation. AJNR Am J Neuroradiol. 2004; 25(5):677–691.
19(3):1233–1239.
16. McDermott, KB, et al. A procedure for identifying regions
preferentially activated by attention to semantic and
phonological relations using functional magnetic resonance
imaging. Neuropsychologia. 2003; 41(3):293–303.
SECT ION 3
BRAIN NETWORK ANATOMY
Outline

Functional Network Overview
Main Text
IM AGING ANATOM Y
Overview
• Numerous proposed brain network parcellations show

similar features with at least 5 core networks common
across methods
Default Mode Network
• Regions: Posterior cingulate/precuneus, medial prefrontal,

inferior parietal (temporoparietal junction), inferior
temporal, hippocampi
• Function: Cognition of internal stimuli, internal narrative,
and evaluative judgment
Attention Control Network
• Subnetworks: Dorsal attention network, ventral attention

network, salience network
• Regions: Frontal eye fields, intraparietal sulcus, dorsolateral
prefrontal, superior insula, middle temporal, inferior
parietal, inferior frontal, lateral orbitofrontal, anterior
cingulate
• Function: Attention to external stimuli, detection of novel
stimuli, working memory, pattern manipulation
Visual Network
• Regions: Occipital lobe, lateral geniculate nuclei of thalamus,

medial posterior parietal
• Function: Perception of visual stimuli, feature and motion
detection, visual attention
Sensorimotor Network
• Subnetworks: Sensorimotor network, auditory network

• Regions: Precentral and postcentral gyrus, primary auditory
cortex, premotor cortex, supplementary motor area, and
ventral lateral and ventral posterior thalamic nuclei
• Function: Perception of somatosensory and auditory stimuli,
planning and execution of muscle movements
Limbic Network
• Regions: Brainstem, amygdala, medial temporal, insula,

orbitofrontal, hypothalamus, basal ganglia, nucleus
accumbens
• Function: Emotive cognition, motivation, learning, reward
processing

• Multiple algorithms have been proposed for parcellating

brain into distributed networks
Automated parcellation algorithms still in research
domain, not yet commercially available
Imaging Approaches
• Independent component analysis
Identifies independent temporal components in BOLD
time series, then locates voxels corresponding best to
each temporal component
May allow overlapping networks
Can use automated template matching to identify
specific components with canonical networks
Often used in groups by concatenating time series and
performing dual regression so individuals have matching
components
• Hierarchical clustering
Small regions of brain are combined based on similar
connectivity to remaining brain, forming dendrogram of
similarity between regions
Dendrogram can be cut at any level, allowing for multiple
levels of detail
• Community detection
Infomap, k-means, expectation maximization, and other
clustering algorithms identify sets of voxels that show
similar functional connectivity to remaining brain
Perform either centroid-based, distribution-based, or
density-based clustering
• Template matching
Using predefined network maps, individual voxels for
new subject can be classified based on which map they
show most similar connectivity to remaining brain
May be less applicable for subjects with distorted
anatomy, such as with tumor or stroke
• Iterative methods
Multiple iterations of clustering may converge to stable
solution for individual or population
Imaging Pitfalls
• All clustering and parcellation methods may fail with single
subject data unless long BOLD acquisitions are performed
given inherently noisy functional connectivity
measurements
Clinical Importance
• Emerging clustering and network identification algorithms

may allow automated brain mapping using only resting
BOLD data for presurgical cases
Requires paradigm shift toward network anatomy
(groups of regions working together) rather than
localism (what does this region do?)
May allow identifying regional boundaries based on their
network connectivity (e.g., separating anterior insula
from Broca area when connectivity shifts from language
network to salience network)
• Shows promise for characterizing neurodevelopmental and
neuropsychiatric disorders based on connectivity
abnormalities
Image Gallery
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FUNCTIONAL BRAIN NETWORK PARCELLATION
A parcellation of the cerebral cortex into 6 networks is
shown. Data were obtained from 1,353 subjects, ages 7-
40, from the 1,000 Functional Connectomes Project and
ADHD-200 datasets. The parcellation represents the best fit
using an infomap parcellation algorithm based on functional
connectivity between each pair of 7,266 nodes covering the
supratentorial gray matter. Results indicate 18 networks
were returned as optimal and the limbic network is a
composite of components 6 through 18.
A parcellation of the cerebral cortex with 180 regions per
hemisphere is adapted from Glasser et al, 2016. Brain
regions were obtained through machine learning analysis of
changes in functional connectivity, task fMRI data, and T1
and T2 signal from structural images across the cortex. A
semiautomated classifier was able to identify homologous
regions at a rate of 99.6% in new subjects, and
corresponds well to known architectonic and
histopathological parcellations from the literature.
CEREBELLAR NETWORK PARCELLATION

Functional network parcellation of the cerebellum. Colors
show a 7-network parcellation of the cerebellum
corresponding to which cortical network each cerebellar
subregion shows highest connectivity, adapted from
Buckner et al, 2011.
INDIVIDUAL VARIATION IN FUNCTIONAL NETWORKS

Data shows how functional subnetworks may vary in
individual subjects. Images show subject 1 (above) and
subject 2 (below), including locations of 2 subnetworks of
the frontoparietal network (FPN), dorsal attention network
(dATN), and default network (DN). [Image is reprinted from
Braga et al (2017) under Creative Commons license.]
Selected References
1. Arslan, S, et al. Human brain mapping: a systematic
comparison of parcellation methods for the human cerebral
cortex. Neuroimage. 2018; 170:5–30.
2. Braga, RM, et al. Parallel Interdigitated distributed
networks within the individual estimated by intrinsic
functional connectivity. Neuron. 2017; 95(2):457. [71.e5].
3. Glasser, MF, et al. A multi-modal parcellation of human
cerebral cortex. Nature. 2016; 536(7615):171–178.
4. Gordon, EM, et al. Generation and Evaluation of a cortical
area parcellation from resting-state correlations. Cereb
Cortex. 2016; 26(1):288–303.
5. Finn, ES, et al. Functional connectome fingerprinting:
identifying individuals using patterns of brain connectivity.
Nat Neurosci. 2015; 18(11):1664–1671.
6. Laumann, TO, et al. Functional system and areal
organization of a highly sampled individual human brain.
Neuron. 2015; 87(3):657–670.
7. Blumensath, T, et al. Spatially constrained hierarchical
parcellation of the brain with resting-state fMRI.
Neuroimage. 2013; 76:313–324.
8. Choi, EY, et al. The organization of the human striatum
estimated by intrinsic functional connectivity. J
Neurophysiol. 2012; 108(8):2242–2263.
9. HD-200 Consortium. The ADHD-200 Consortium: a model
to advance the translational potential of neuroimaging in
clinical neuroscience. Front Syst Neurosci. 2012; 6:62.
10. Lee, MH, et al, Clustering of resting state networks. PLoS
One 7 7 2012 e40370
11. Buckner, RL, et al. The organization of the human
cerebellum estimated by intrinsic functional connectivity. J
Neurophysiol. 2011; 106(5):2322–2345.
12. Power, JD, et al. Functional network organization of the
human brain. Neuron. 2011; 72(4):665–678.
13. Yeo, BT, et al. The organization of the human cerebral
cortex estimated by intrinsic functional connectivity. J
Neurophysiol. 2011; 106(3):1125–1165.
14. Biswal, BB, et al. Toward discovery science of human brain
function. Proc Natl Acad Sci U S A. 2010; 107(10):4734–4739.
15. He, Y, et al, Uncovering intrinsic modular organization of
spontaneous brain activity in humans. PLoS One 4 4 2009
e5226
16. Smith, SM, et al. Correspondence of the brain’s functional
architecture during activation and rest. Proc Natl Acad Sci U
S A. 2009; 106(31):13040–13045.
Neurotransmitter Systems
Main Text
IM AGING ANATOM Y
Overview
• Glutamate and GABA are primary neurotransmitters in

brain
Glutamate is main excitatory neurotransmitter in brain
– Glutamate excitotoxicity occurs from overproduction
of glutamate
GABA is main inhibitory neurotransmitter in brain
– Glycine is primary inhibitory neurotransmitter in
spinal cord
Balance of GABA/glutamate hypothesized in
pathophysiology of many psychiatric and
neurodevelopmental syndromes
• Neuromodulatory pathways may be mediated by other
neurotransmitters, neuropeptides, and brain hormones
Dopamine
• Synthesized in substantia nigra (SN), ventral tegmental area,

and hypothalamus
• 5 types of receptors (D1-D5)
D1-like (D1, D5) effects and D2-like (D2, D3, D4) effects
D1 receptors in hippocampus, caudate, putamen,
nucleus accumbens, hypothalamus, SN pars reticulata,
olfactory tubercle, frontal and temporal cortex
D2 receptors in basal ganglia, septum, ventral tegmental
area, nucleus accumbens
Presynaptic D2 receptors regulate release of dopamine
through negative feedback
• Nigrostriatal pathway
Originates in pars compacta of midbrain's SN
Connects SN to dorsal striatum (caudate and putamen)
More important for extrapyramidal motor control than
sexual and motivation function
Modulates both direct pathway for motor function
(decreasing striatal GABA to thalamus to facilitate
movements) and indirect pathway (increases GABA to
thalamus to inhibit movements)
Minor role in reward and reinforcement memory and
learning
• Mesolimbic pathway
Primary reward and pleasure circuit in brain
Originates in ventral tegmental area
Projects to ventral striatum (especially nucleus
accumbens), thalamus, piriform cortex, amygdala, lateral
septal nuclei
Activated by rewarding stimuli (food, music, sex, novelty,
religious experience, romantic and parental bonding,
euphoria)
Stimulated directly or indirectly by all known drugs of
abuse
• Mesocortical pathway
Originates in ventral tegmental A10 region and projects
to frontal cortex (especially orbitofrontal and cingulate)
and septohippocampal regions
Modulates working memory and attention (dose
dependent: Impaired memory if hyperactive)
• Tuberoinfundibular pathway
Originates in arcuate and paraventricular nuclei of
hypothalamus and projects to median eminence of
pituitary
Inhibits prolactin release
Norepinephrine
• Produced in locus coeruleus and lateral tegmental regions

from dopamine
Inactive during sleep (especially REM), baseline level
during wakefulness, and elevated during pain, fear, or
dysphoria
• Projects to spinal cord, cerebellum, hypothalamus (preoptic
area), tectum, thalamus, basal ganglia, amygdala, olfactory
bulb, and cortex
• Promotes "fight or flight" sympathetic-autonomic responses,
sexual behavior, appetite control, alertness, arousal
• Similar effects to humoral epinephrine produced by adrenal
glands
• α 1, 2 and β 1, 2, 3 receptors
α 1 and 2 throughout brain and cerebral vasculature
β 1 more numerous in cortex, β 2 greater in cerebellum
Serotonin
• Synthesized in caudal (15%) and rostral (85%) raphe nuclei

• Project to amygdala (basal nucleus), nucleus accumbens,
striatum, thalamus, hypothalamus, cerebellum, spinal cord,
cortex (ventromedial and dorsolateral prefrontal)
• Modulatory roles in mood, cognition, respiration, feeding,
locomotion, memory, social function
• Receptors include 5-HT 1 to 5-HT 7 receptors, many with
multiple subtypes (e.g., 5-HT 1A-F)
Unique contributions to function of individual receptor
subtypes still incompletely understood
• Simulation (psilocybin) or stimulation (MDMA) can result in
elevated mood, social bonding, hallucinations or heightened
perception, reduced appetite, agitation, dry mouth,
hyperthermia
Acetylcholine
• Produced in basal forebrain (esp. nucleus basalis), medial

septal group, and pontine tegmental nuclei
• Projects widely throughout brain, including olfactory bulb,
hypothalamus, hippocampus, amygdala, tectum, thalamus,
and cortex
• Activates muscarinic and nicotinic receptors (primarily M1
in brain)
• Modulates arousal, attention, and memory
Minor Neurotransmitters
• Histamine : Produced in tuberomamillary nucleus (posterior

hypothalamus) and projects throughout brain
Involved in arousal, pituitary neuroendocrine function,
feeding, cognition, sleep-wake behaviors
• ATP : Mediator in neuronal-glial and glial-glial signaling
Neuromodulatory function via synaptic P2X receptors
Neuropeptide Systems
• Endogenous opioids include enkephalins, dynorphins, and

endorphins, released by neurons
Proopiomelanocortin neurons (endorphin precursor)
synthesized in arcuate nucleus of hypothalamus and
medulla nucleus tractus solitarius, project throughout
central nervous system (CNS)
Other precursors (PENK, PDYN, PNOC) throughout
neocortex, hippocampus, thalamus, basal ganglia,
hypothalamus, brainstem
Opioids (synthetic and endogenous) activate 3 opioid
receptors: µ, δ, and κ
– µ and δ receptors facilitate analgesia in anterior
cingulate, amygdala, periaqueductal gray, rostral
medulla
– δ receptors are neuroprotective against hypoxic
injury
– µ receptors primary mediators of euphoria (inhibit
GABA release to facilitate dopamine in nucleus
accumbens)
Opposite effect from κ receptors
Effects on analgesia, respiratory depression, vasopressin
release, cardiovascular homeostasis, euphoria
• Oxytocin and arginine-vasopressin ( AVP ) are synthesized
in hypothalamus and released in posterior pituitary
Hypothesized roles in nociception, analgesia, social
function, lactation
Oxytocin receptors and AVP receptors (V1a, V1b, V2)
highest in social decision-making regions: Ventromedial
hypothalamus, bed nucleus of stria terminalis, nucleus
accumbens, basal forebrain, amygdala
• Numerous other neuropeptides in brain and gut: CCK,
neuropeptide Y, somatostatin, VIP, substance P,
neurotensin, neuropeptide Y, galanin
Endocannabinoid System
• Endogenous cannabinoid compounds include lipids that

engage cannabinoid receptors
Anandamide and 2-AG are liberated enzymatically and
released into extracellular space
Bind to CB1 and CB2 receptors (CB2 likely not functional
in healthy CNS)
CB1 receptors present in cortex, basal ganglia,
hippocampus, and cerebellum
• Delta-9-THC (from cannabis plant) is potent CB1 agonist
THC allosteric modulator of µ- and δ-opioid receptors
Euphoria from THC likely through increased dopamine
synthesis and release
• Cannabidiol (CBD) most prominent of dozens of other
cannabinoids, has weak or no affinity for CB1 receptors
CBD and THC have many opposing effects on brain,
with euphoria primarily through THC
• Numerous terpene compounds also present in low
concentrations with unclear neuroactive effects
Neuroendocrine Pathways
• Hypothalamic-pituitary axis consists of releasing factors in

hypothalamus and anterior pituitary hormones with
humoral actions
GHRH, somatostatin control growth hormone release
Dopamine stimulates prolactin release
GnRH stimulates FSH, LH release
TRH stimulates TSH release
CRH stimulates ACTH release
Clinical Importance
• Movement disorders
Loss of nigrostriatal dopaminergic neurons leads to
difficulty in initiating and controlling movements
D2 receptor blockade via antipsychotics can trigger
parkinsonian symptoms
Hyperactivity of nigrostriatal dopamine can result in
chorea, tics, and dyskinesias
• Major depression
Modulated by dopamine, norepinephrine, opioid, and
serotonin pathways through multiple mechanisms
• Schizophrenia
Hyperactivity of dopaminergic mesolimbic activity
contributes to positive psychotic symptoms (treated
with D2 receptor blockade)
Negative symptoms of schizophrenia produced by
mesocortical dopamine blockade
• Alzheimer disease
Associated with loss of cholinergic neurons in basal
forebrain
• Addiction
Involves modulation and plasticity of dopaminergic
mesolimbic pathway
Image Gallery
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DISTRIBUTION OF KEY NEUROTRANSMITTER SYSTEMS
Graphic shows locus coeruleus and lateral tegmental loci
that produce norepinephrine, and arrows show major
synaptic connections between these loci and other brain
regions. Noradrenergic outputs show widespread
innervation of the brainstem, thalamus, neocortex,
cerebellum, hypothalamus, and spinal cord.
Serotonergic neurons in the raphe nuclei project to the
brainstem, striatum, thalamus, hypothalamus, orbitofrontal
and anterior cingulate cortex, cerebellum, amygdala,
nucleus accumbens, and spinal cord.
Cholinergic pathways in the brain are shown. Acetylcholine
is produced in neurons in the medial septal group, nucleus
basalis, and pontine tegmental nuclei with widespread
projections to the cortex, thalamus, brainstem, hippocampus
and amygdala, medial habenular nucleus, and optic tract.
DOPAMINERGIC OUTPUTS AND DATSCAN

Graphic shows 4 pathways for dopaminergic
neurotransmission: Nigrostriatal pathway (blue) originates in
substantia nigra and innervates the dorsal striatum.
Mesolimbic pathway (yellow) connects the ventral tegmental
area to ventral striatum and amygdala. Mesocortical
pathway connects the ventral tegmental A10 region to the
frontal cortex. Tuberoinfundibular pathway originates in the
arcuate and paraventricular nuclei of the hypothalamus and
projects to the median eminence of the pituitary gland.
A fused SPECT-CT is shown from a DaTscan (Ioflupane I
123) demonstrating normal activity within the bilateral
striatum. The DaTscan measures binding to the dopamine
transporter in the caudate and putamen. (Courtesy K.
Morton, MD.)
Selected References
1. Bruinsma, TJ, et al. The relationship between dopamine
neurotransmitter dynamics and the blood-oxygen-level-
dependent (BOLD) signal: a review of pharmacological
functional magnetic resonance imaging. Front Neurosci.
2018; 12:238.
2. Covey, DP, et al. Endocannabinoid modulation of
dopamine neurotransmission. Neuropharmacology. 2017;
124:52–61.
3. Harmer, CJ, et al. How do antidepressants work? New
perspectives for refining future treatment approaches.
Lancet Psychiatry. 2017; 4(5):409–418.
4. Lu, HC, et al. An introduction to the endogenous
cannabinoid system. Biol Psychiatry. 2016; 79(7):516–525.
5. North, RA. P2X receptors. Philos Trans R Soc Lond B Biol Sci.
371(1700), 2016.
6. Shamay-Tsoory, S, et al. Understanding the oxytocin
system and its relevance to psychiatry. Biol Psychiatry.
2016; 79(3):150–152.
7. Barth, C, et al. Sex hormones affect neurotransmitters and
shape the adult female brain during hormonal transition
periods. Front Neurosci. 2015; 9:37.
8. Berridge, KC, et al. Pleasure systems in the brain. Neuron.
2015; 86(3):646–664.
9. Herring, BE, et al. Is aspartate an excitatory
neurotransmitter? J Neurosci. 2015; 35(28):10168–10171.
10. Tuominen, L, et al. Mapping neurotransmitter networks
with PET: an example on serotonin and opioid systems.
Hum Brain Mapp. 2014; 35(5):1875–1884.
11. Benarroch, EE. Endogenous opioid systems: current
concepts and clinical correlations. Neurology. 2012;
79(8):807–814.
12. Khakh, BS, et al. Neuromodulation by extracellular ATP and
P2X receptors in the CNS. Neuron. 2012; 76(1):51–69.
13. Montoya, ER, et al. Testosterone, cortisol, and serotonin as
key regulators of social aggression: a review and theoretical
perspective. Motiv Emot. 2012; 36(1):65–73.
14. Charnay, Y, et al. Brain serotonergic circuitries. Dialogues
Clin Neurosci. 2010; 12(4):471–487.
15. Nuutinen, S, et al. Histamine in neurotransmission and
brain diseases. Adv Exp Med Biol. 2010; 709:95–107.
16. Berridge, KC, et al. Dissecting components of reward:
‘liking’, ‘wanting’, and learning. Curr Opin Pharmacol. 2009;
9(1):65–73.
17. Langmead, CJ, et al. Muscarinic acetylcholine receptors as
CNS drug targets. Pharmacol Ther. 2008; 117(2):232–243.
18. Wang, HY, et al. beta-Amyloid(1-42) binds to alpha7
nicotinic acetylcholine receptor with high affinity.
Implications for Alzheimer’s disease pathology. J Biol Chem.
2000; 275(8):5626–5632.
19. Fonnum, F. Glutamate: a neurotransmitter in mammalian
brain. J Neurochem. 1984; 42(1):1–11.
Main Text
IM AGING ANATOM Y
Overview
• Set of brain regions activated during stimulus-independent

thought
• Includes 3 subnetworks: Dorsal medial prefrontal, medial
temporal, and core hubs
Dorsal medial prefrontal subsystem: Introspection of
mental states of others (theory of mind), social
reasoning; includes temporoparietal junction, anterior
temporal pole, and inferolateral temporal areas
Medial temporal lobe subsystem: Episodic and
autobiographical memory, imagery, navigation; includes
medial temporal lobe, retrosplenial cortex, subgenual
ventromedial regions
Core hubs: Self-referential processing, mentalizing, future
planning, moral reasoning; includes precuneus, anterior
medial prefrontal cortex at center of default mode
network (DMN) nodes
• Left-dominant interconnections with core language regions
facilitating semantic memory and internal narrative
• Analogues of DMN have been identified in rats and
nonhuman primates
• Also termed default network, task-negative network
Network Hubs
• Posterior cingulate/precuneus
• Medial prefrontal
• Inferior parietal (temporoparietal junction)
• Inferior temporal
• Hippocampi
Function
• Attention to internal stimuli

• Processing of internal narrative (talking to oneself)
• Autobiographical/semantic memory
• Mind wandering
• Self-referential thought
• Meditation
• Future planning
• Theory of mind cognition
• Social reasoning
• Moral decision making

• Default mode regions can be identified by BOLD

deactivations during attentional tasks, functional
connectivity MR, and task-based examination of
autobiographical memory, mind wandering, and cognition
of internal stimuli
Imaging Pitfalls
• Anticorrelations between attentional and DMNs may be

exaggerated by preprocessing steps such as global signal
regression
Clinical Importance
• Dementia: Decreased connectivity between hubs of DMN in

mild cognitive impairment and Alzheimer disease
Neuropathology of Alzheimer disease (amyloid plaques)
appears preferentially in DMN regions
• Major depression: Hyperactivity of medial prefrontal node
of DMN with failure to deactivate during attentional tasks
• Autism: Decreased connectivity between anterior and
posterior hubs of DMN and failure to deactivate DMN
during attentional tasks
• Schizophrenia: Decreased suppression of DMN during
attentional tasks
• Disorders of consciousness (persistent vegetative state,
minimally conscious state, sleep): Decreased DMN
connectivity with decreasing consciousness
Image Gallery
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DEFAULT NETWORK REGIONS
The default mode network cluster is shown from a 6-
network parcellation of the brain based on whole-brain
functional connectivity from 1,353 subjects. Voxels within
this cluster were colored based on mean functional
connectivity to 4 seeds selected in the posterior
cingulate/precuneus, medial prefrontal, and bilateral
temporoparietal junction. In addition to the seed regions,
additional hubs of this network include bilateral inferior
temporal and bilateral hippocampal regions.
DEFAULT AND ATTENTION CONTROL NETWORKS

Image shows regions of the default network of the brain,
obtained from a network parcellation of 1,353 subjects.
Default network and attention control network regions are
shown. The 2 broad networks cover the association cortex,
and each functional hub of the default network shows a
corresponding hub of the attention control network.
INDIVIDUAL VARIATION OF DEFAULT NETWORK

The default network has anterior and posterior
subnetworks, shown in 2 subjects (above and below) in the
image. Individual variation in the position of subnetwork
components as shown may limit the ability to detect
subnetworks in population studies where data from many
individuals is averaged. Image is reprinted under creative
commons license from Braga et al (2017).
Selected References
1. Braga, RM, et al. Parallel interdigitated distributed networks
within the individual estimated by intrinsic functional
connectivity. Neuron. 2017; 95(2):457. [71.e5].
2. Anticevic, A, et al. The role of default network deactivation
in cognition and disease. Trends Cogn Sci. 2012; 16(12):584–
592.
3. Buckner, RL. The serendipitous discovery of the brain’s
default network. Neuroimage. 2012; 62(2):1137–1145.
4. Spencer, MD, et al. Failure to deactivate the default mode
network indicates a possible endophenotype of autism. Mol
Autism. 2012; 3(1):15.
5. Sestieri, C, et al. Episodic memory retrieval, parietal cortex,
and the default mode network: functional and topographic
analyses. J Neurosci. 2011; 31(12):4407–4420.
65(4):550–562.
7. Sheline, YI, et al. Amyloid plaques disrupt resting state
default mode network connectivity in cognitively normal
elderly. Biol Psychiatry. 2010; 67(6):584–587.
8. Spreng, RN, et al. Patterns of brain activity supporting
autobiographical memory, prospection, and theory of mind,
and their relationship to the default mode network. J Cogn
Neurosci. 2010; 22(6):1112–1123.
9. Sheline, YI, et al. The default mode network and self-
referential processes in depression. Proc Natl Acad Sci U S
A. 2009; 106(6):1942–1947.
10. Uddin, LQ, et al. Functional connectivity of default mode
network components: correlation, anticorrelation, and
causality. Hum Brain Mapp. 2009; 30(2):625–637.
1124:1–38.
12. Fair, DA, et al. The maturing architecture of the brain’s
default network. Proc Natl Acad Sci U S A. 2008;
105(10):4028–4032.
13. Fransson, P, et al. The precuneus/posterior cingulate cortex
plays a pivotal role in the default mode network: evidence
from a partial correlation network analysis. Neuroimage.
2008; 42(3):1178–1184.
14. Harrison, BJ, et al. Consistency and functional specialization
in the default mode brain network. Proc Natl Acad Sci U S A.
2008; 105(28):9781–9786.
15. Mason, MF, et al. Wandering minds: the default network
and stimulus-independent thought. Science. 2007;
315(5810):393–395.
16. Raichle, ME, et al. A default mode of brain function: a brief
history of an evolving idea. Neuroimage. 2007; 37(4):1083–
1090. [discussion 1097-9].
17. Greicius, MD, et al. Default-mode network activity
distinguishes Alzheimer’s disease from healthy aging:
evidence from functional MRI. Proc Natl Acad Sci U S A.
2004; 101(13):4637–4642.
18. Greicius, MD, et al. Functional connectivity in the resting
brain: a network analysis of the default mode hypothesis.
19. Raichle, ME, et al. A default mode of brain function. Proc
Natl Acad Sci U S A. 2001; 98(2):676–682.
Attention Control Network
Main Text
T ERM INOLOGY
Definitions
• Working memory: Manipulation and processing of object,

cognitive, or stimulus representations in brain, including
rehearsal, analysis, and comparison of stimuli
• Hemispatial neglect: Deficits in salience detection and
spatial attention of portion of egocentric space; usually
associated with right hemisphere injury and impaired
attention to stimuli on patient's left side
• Attention control network: Union of dorsal, ventral, and
salience attentional networks (a.k.a. task-positive network);
distributed brain network involved in control of attention
and working memory
IMAGING ANATOMY
Overview
• Attention, working memory, executive control, and novelty

detection share overlapping distributed networks that are
dedicated to processing and analysis of external stimuli
• Each node of network
Contains "map" of cognitive space, topographically
connected to other nodes
Represents different types of cognitive information about
external stimuli
• 3 attentional subnetworks are present: Dorsal attention,
ventral attention, and salience
Dorsal Attention Network
• Voluntary control of attentional focus and goal-directed

behavior
• Intraparietal sulcus (IPS)
Contains a representation of cognitive space organized
topographically by sensory modality and multiple
egocentric reference frames of contralateral space
Activity in 1 part of IPS results in increased sensitivity of
related areas of sensory cortex, resulting in "attending"
to that region of space and modality of sensation
Likely competition for attention between different
subregions of IPS and between hemispheric
homologues; regions of greatest activity control content
of attention
• Frontal eye fields (FEFs) and supplementary eye fields
(SEFs)
Direct eye movements toward stimuli of interest
Also include SEF regions
• Middle temporal (MT)
Processes dynamic changes in external stimuli such as
motion perception
• Dorsolateral prefrontal cortex
Active during working memory tasks, manipulation of
multiple object representations, cognitive operations on
external or abstract stimuli
Ventral Attention Network
• Control of reorienting to relevant stimuli

• Supramarginal and angular gyri
Lateral extension of IPS in dorsal attention network
• Inferior frontal gyrus
Lateral correlate of FEFs/SEFs in dorsal attention
network
• Ventral attention network is right dominant, analogous to
Broca and Wernicke areas in left hemisphere
Salience Network
• Detection of novel or salient stimuli

• Anterior insula (frontoinsular cortex) and anterior cingulate
are active when a stimulus is novel, salient, or rewarding;
associated with mesolimbic reward pathways from ventral
tegmentum to nucleus accumbens and cortex
Salience network is activated by salient stimuli regardless
of modality of stimulus
• Anterior insula
Superior anterior insula associated with novelty of
external stimuli
Inferior anterior insula associated with novelty of
emotive stimuli, more connections to limbic regions
• Anterior cingulate
Dorsal anterior cingulate more associated with novel
external stimuli
Ventral (pregenual) anterior cingulate more associated
with emotive salience
Accessory Attentional Regions
• Cerebellar attentional regions

Bilateral superior lateral and inferior lateral cerebellar
hemispheres show greatest connectivity to cortical
attention control network
Attentional sequelae of isolated injuries in attentional
regions of cerebellum are not well characterized
• Basal ganglia
Subcortical pathways of reward processing likely interact
with cortical attentional networks through basal ganglia
Dopamine is a powerful regulator of attention and
salience
Damage to basal ganglia leads to abulia (apathy without
dysphoria)
May modulate motivational drive, reward, and arousal
associated with attention
Superior Longitudinal Fasciculus White Matter Pathway
• Transmits core frontoparietal attentional network

connections between FEFs and IPS
Arcuate Fasciculus Homologue White Matter Pathway
• Right-dominant connection between inferior frontal gyrus

and inferior parietal regions of ventral attention network
• Attentional information in right hemisphere is analogous to
language pathway in left hemisphere

• Salience tasks
Oddball task (visual or auditory): Acknowledge a rare
stimulus from presentation of more common stimuli
• Working memory tasks
N-back task: Compare a stimulus to one presented in
iterations previously
Paced auditory serial addition test (PASAT) task: Add
the last 2 of a string of numbers presented continuously
Sternberg task: Groups of letters or numbers are
presented, followed by a test letter or number; subjects
are asked if test stimulus was 1 of stimuli presented in
previous iterations
• Response inhibition tasks
Go/no go: Subjects perform 1 action to 1 set of stimuli
but suppress the action for other sets of stimuli
• Spatial attention tasks
Embedded figures task: Find a geometric feature
embedded within a more complex diagram
Oculomotor task: Follow a moving cursor on screen with
eyes compared to a fixation point
Pattern comparison: Compare 2 images on screen to
evaluate differences between them
Imaging Pitfalls
• Attentional deficit mimics include depression, poor

motivation, brainstem dysfunction, and poor alertness
Attention Organized by Sensory Modality
• Visual attention medial, auditory attention lateral,

somatosensory attention anterior along IPS
• Similar maps in other attentional hubs, sometimes inverted,
with variable size of sensory modalities
Topographical Connections Between Attention Hubs
• Each hub of attention control network has subregions for

visual, auditory, somatosensory, and other stimuli, likely
each with 1 or more spatial maps
• Hubs are connected by topographic connections to other
hubs that preserve modality and spatial-specific
organization
• Attentional regions typically located in association cortex in
regions spatially "equidistant" from primary sensory area
Flow of information from primary sensory to unimodal
sensory association cortex to polymodal association
cortex
Gradients of Internal vs. External Stimulus Attention
• Attention control network is anticorrelated to default

network: When one is more active, the other tends to be less
active
Internal stimuli (default mode network) compete with
external stimuli (attention control network) for activity
Allows focus of attention to shift between internal and
external stimuli
• Accomplished by gradients of connectivity between the 2
networks ranging from coactivation to suppression of the
other network
Disorders of Attention
• Spatial neglect
Most common after right hemisphere injury to ventral
attention network (including homologues of Broca and
Wernicke areas) and connecting white matter pathways
– Just as language is typically left dominant, attention
is right dominant in most people
Generalized deficits (not linked to particular region of
space) of reorienting, target detection, and arousal are
created by injury to right ventral attentional network
Right ventral attention network injury also causes left >
right imbalance in dorsal attention network and results
in deficits of left-sided salience detection and spatial
attention
Injury to right dorsal attention network can also result in
goal-driven shift of attention and eye movements but
does not typically produce full spatial neglect syndrome
• Attention deficit hyperactivity disorder
Increased connectivity has been seen between insula and
anterior cingulate cortex
Decreased connectivity has been seen between anterior
cingulate and posterior cingulate/precuneus
Image Gallery
Print Images
CORE ATTENTION REGIONS
Hubs of the attention control network are shown. The 1st
image reveals functional connectivity to 4 seeds in the
bilateral intraparietal sulcus and bilateral anterior insula. The
color scale shows mean functional connectivity to the seeds
across 1,019 healthy control subjects (range: 0.15-0.40).
Included are hubs of the dorsal attention network [frontal
eye fields (FEFs), intraparietal sulcus (IPS), middle
temporal (MT), and dorsolateral prefrontal cortex], ventral
attention network (inferior frontal gyrus,
angular/supramarginal gyri), and salience network (frontal
insula, anterior cingulate cortex).
Same dataset as the previous image, shown in slices,
allows better visualization of anterior insula hubs. Bright red
regions represent the locations of the seeds used for the
analysis.
TOPOGRAPHIC MAPS OF COGNITIVE SPACE

IPS map of cognitive space shows domains of auditory,
visual, somatosensory, internal, and polymodal stimulus
attention across the IPS. Each subregion likely contains 1 or
more topographic representations of space, best
documented for visual attentional regions (IPS1, IPS2,
IPS3, IPS4). Other hubs of the attention control network
also show subregions with different sensory modalities
topographically connected to the IPS.
Graphic shows the attention control network with
subregions of each hub of the network demonstrating
greatest connectivity to visual vs. auditory vs.
somatosensory cortex. Each hub of the network is
topographically connected to other hubs of the network so
that similar functional subregions are most connected.
ATTENTIONAL SUBNETWORKS
Subnetworks of the attention control network are shown.
The mask of attention control network regions was obtained
from brain voxels correlated with r > 0.15 to 4 seeds in the
bilateral IPS and bilateral superior insula in 1,353 subjects.
Functional connectivity was calculated for each voxel within
this mask to 7,266 gray matter regions, and voxels were
parcellated into 3 clusters using a k-means algorithm based
on similar connectivity to the rest of the brain. The voxels in
blue show characteristic distribution of the dorsal attention
network, including FEFs, IPS, and MT areas. The voxels in
green show characteristic distribution of the salience
network, including insula and dorsal anterior cingulate
areas. The voxels in red show a distribution most consistent
with the ventral attention network, including dorsolateral
prefrontal, inferior frontal, ventral anterior cingulate, and
supramarginal gyrus areas.
LATERALITY OF ATTENTIONAL REGIONS
Hubs where functional connections are stronger in the left

vs. right hemisphere across a sample of 1,011 individuals
are shown. Right-hemispheric hubs include regions
comprising brain attentional networks, which are right-
dominant systems. Figure obtained from Nielsen et al.
(2013).
Connectivity to right-dominant hubs is shown. Images show
functional connectivity to each seed (black dots), with
connections that are stronger in the right hemisphere in cool
colors and connections that are stronger in the left
hemisphere in warm colors. Image obtained from Nielsen et
al. (2013).
Selected References
1. Dugué, L, et al. Specific visual subregions of TPJ mediate
reorienting of spatial attention. Cereb Cortex. 2018;
28(7):2375–2390.
2. Zhou, Y, et al. The hierarchical organization of the default,
dorsal attention and salience networks in adolescents and
young adults. Cereb Cortex. 2018; 28(2):726–737.
3. Kucyi, A, et al. Dynamic brain network correlates of
spontaneous fluctuations in attention. Cereb Cortex. 2017;
27(3):1831–1840.
4. Rosenberg, MD, et al. A neuromarker of sustained attention
from whole-brain functional connectivity. Nat Neurosci.
2016; 19(1):165–171.
5. Shine, JM, et al. Temporal metastates are associated with
differential patterns of time-resolved connectivity, network
topology, and attention. Proc Natl Acad Sci U S A. 2016;
113(35):9888–9891.
6. Uddin, LQ. Salience processing and insular cortical
function and dysfunction. Nat Rev Neurosci. 2015; 16(1):55–
61.
7. Bray, S, et al. Structural connectivity of visuotopic
intraparietal sulcus. Neuroimage. 2013; 82:137–145.
8. Nielsen, JA, et al, An evaluation of the left-brain vs. right-
brain hypothesis with resting state functional connectivity
magnetic resonance imaging. PLoS One 8 8 2013 e71275
9. Spreng, RN, et al. Intrinsic architecture underlying the
relations among the default, dorsal attention, and
frontoparietal control networks of the human brain. J Cogn
Neurosci. 2013; 25(1):74–86.
10. Petersen, SE, et al. The attention system of the human brain:
20 years after. Annu Rev Neurosci. 2012; 35:73–89.
11. Anderson, JS, et al. Connectivity gradients between the
default mode and attention control networks. Brain Connect.
2011; 1(2):147–157.
12. Corbetta, M, et al. Spatial neglect and attention networks.
Annu Rev Neurosci. 2011; 34:569–599.
13. Thiebaut de Schotten, M, et al. A lateralized brain network
for visuospatial attention. Nat Neurosci. 2011; 14(10):1245–
1246.
Neurophysiol. 2011; 106(3):1125–1165.
15. Anderson, JS, et al. Topographic maps of multisensory
attention. Proc Natl Acad Sci U S A. 2010; 107(46):20110–
20114.
16. Verdon, V, et al. Neuroanatomy of hemispatial neglect and
its functional components: a study using voxel-based
lesion-symptom mapping. Brain. 2010; 133(Pt 3):880–894.
17. Reynolds, JH, et al. The normalization model of attention.
Neuron. 2009; 61(2):168–185.
18. Castellanos, FX, et al. Cingulate-precuneus interactions: a
new locus of dysfunction in adult attention-
deficit/hyperactivity disorder. Biol Psychiatry. 2008;
63(3):332–337.
19. Dosenbach, NU, et al. A dual-networks architecture of top-
down control. Trends Cogn Sci. 2008; 12(3):99–105.
20. Seeley, WW, et al. Dissociable intrinsic connectivity
networks for salience processing and executive control. J
Neurosci. 2007; 27(9):2349–2356.
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sulcus. J Neurosci. 2007; 27(20):5326–5337.
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human dorsal and ventral attention systems. Proc Natl Acad
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Sensorimotor Network
Main Text
T ERM INOLOGY
Abbreviations
• Primary motor cortex (PMC)

• Premotor cortex area (PMA)
• Supplementary motor area (SMA)
• Deep gray nuclei [basal ganglia (BG), red nucleus,
subthalamic nucleus, brainstem]
IMAGING ANATOMY
Overview
• PMC (M1, area 4) in precentral gyrus

Origin of majority of corticospinal tracts and
corticobulbar fibers, particularly those controlling motor
cranial nerves
Projections to thalamus and BG
– Input from ventral lateral nucleus of thalamus,
sensory cortical areas, premotor cerebral regions
– Well-defined somatotopic organization of motor
cortex
– Movements can be generated by lowest intensity of
electrical stimulation
– Specific movements tend to be represented rather
than specific muscles
Parallel input from SMA, PMA, BG, cerebellum
Primary function in execution as well as some planning
of movement
Lesions produce spastic contralateral weakness, most
prominent in distal extremities
• Premotor cortex (area 6) lies anterior to M1 with many of
same connections as motor cortex
Most output is to M1 with smaller output to brainstem
and spinal cord
Receives input from sensory association cortex and
feedback from BG via ventral anterior and ventral lateral
thalamic nuclei
Electrical stimulation produces more complex
movements and at higher stimulus intensity than simple
movements from M1
Primarily responsible for initiation and planning of
movement
– Generates complex motor plans in response to
external cues
Helps guide body movements by integrating sensory
information
– Controls muscles that are closest to body main axis
Lesions produce less severe weakness but greater
spasticity than with isolated precentral gyrus lesions
• SMA: Area in medial superior frontal gyrus (Brodmann area
6) anterior to PMC and superior to cingulate sulcus
Midline defines its medial limit; its anterior boundary is
defined by line perpendicular to rostrum of corpus
callosum
Divided into rostral and caudal aspects by V line :
Vertical line traversing posterior margin of anterior
commissure
– Rostral SMA (pre-SMA) activates during word-
generation and working-memory tasks
– Caudal SMA activates during motor and sensory
tasks
– Rostral SMA is particularly active during learning of
new sequential procedures
– Caudal SMA is active during performance of
sequential movements
SMA receives input from motor and premotor cortices
and from sensory cortex
Projects to M1, BG, thalamus, brainstem, and
contralateral SMA
Thought to be involved in initiation of motion, planning
complex movements, coordinating movements involving
both hands
– Generates motor plans in response to internal cues,
automatic motor responses
Lesions of this area can cause inability to initiate motions
(abulia), motor apraxia, transient weakness
– Can result in severe deficits that improve or resolve
over 6 weeks (SMA syndrome)
During complex motor and heat sensory tasks, activation
tends to occur in contralateral posterior portion of SMA
Word-generation and working-memory tasks tend to
produce activation in anterior portion of SMA,
particularly on left
• BG
Overlap as well as segregation among connections of
motor cortices with striatum and thalamus
– Supports notion that neuronal information of motor
cortices is funneled in control of volitional
movement
Seem to be activated more by sequential or internally
cued movement than by repetitive or externally cued
movement
May be involved in velocity of movement
– BG-thalamo-motor loop plays important role in
controlling rate of sequential finger movements in
self-initiated movement but not in externally
triggered movement
• Thalamus
Influences descending, corticobulbar, and corticospinal
motor pathways that originate in motor and premotor
areas of cerebral cortex
– All thalamic nuclei, with exception of reticular
thalamic nucleus, project primarily to cortex
• Cerebellum
Plays role in automatic execution of ipsilateral
movements, motor learning, fine motor control,
vestibulomotor function
2 distinct motor nuclei bilaterally in superior and inferior
cerebellar cortex
• Cerebral networks involved in integrative processing of

somesthetic inputs for kinesthetic purposes
i.e., how muscle proprioceptive and tactile messages
result in perception of one's own body movements
Proprio-tactile costimulation activates inferior parietal
lobule, superior temporal sulcus, insula-claustrum
region, and cerebellum
– Detection of spatial coherence between 2 kinesthetic
messages involves inferior parietal lobule activity
– Detection of temporal coincidence via subcortical
relay, insula structure; usually linked to relative
synchrony of different stimuli
– Superior temporal sulcus involved in feeling of
biological movement
• Functional connectivity
Spontaneous firing of neurons (even in resting state)
increases local blood flow, causes MR signal
fluctuations, and affects remotely located neurons
through efferent output
– Possible to detect neurons connected to selected
region by calculating covariance of each voxel
referenced to time course of selected brain region
Early phases of learning: Activation of wide areas of
primary sensorimotor cortex, PMA, SMA
– Increased coherence between these areas as
compared to later stages of learning
Histology
• Cerebral neocortex consists of 6 layers from superficial to

deep: Molecular (layer 1), external granular (layer 2),
external pyramidal (layer 3), internal granular (layer 4),
internal pyramidal (layer 5), and multiform (layer 6)
PMC is agranular cortex, and layers 3 and 5 are
prominent with layers 4 and 6 being barely detectable
Primary sensory cortex is granular cortex, and layers 4
and 6 are prominent
Both cortices have more myelin content than other
adjacent cortices

• Finding central sulcus on transverse MR

Superior frontal sulcus is vertically oriented, intersects
with horizontal central sulcus → L shape
"Hand knob" of central sulcus, representing motor
neurons involved in hand movements, has shape of
inverted Ω
Medial extent of central sulcus lies just anterolateral to
pars marginalis, which looks like moustache
• Higher mean cortical thickness ratio across central sulcus
• On fast FLAIR images, perirolandic cortex generally has low
signal intensity in neurologically normal brain
Imaging Pitfalls
• Intracranial lesions and associated mass effect and edema

can distort anatomy, making it difficult to use normal
anatomic landmarks to localize functional areas
Clinical Importance
• Preoperative planning
High agreement between fMRI localization of
sensorimotor function and localization by means of
invasive neurosurgical methods
For hand motor function alone, one study found
sensitivity and specificity were 88% and 87%,
respectively
Development
• fMRI can depict different maturation stages of sensorimotor

system within 1st year of life
• On passive sensorimotor stimulation, cortical activation
pattern around term-equivalent age involves bilateral
sensorimotor cortices
Indexed as both positive and negative blood-oxygen-level
dependent (BOLD) responses
• Predominantly contralateral activations of sensorimotor
cortex (e.g., positive BOLD responses only) between months
3 and 9 of life
• Congenital disorders
In patients with schizencephaly, increased activation in
unaffected hemisphere may reflect functional
reorganization of M1
Functional Imaging Tasks
• Hand
Unilateral/bilateral finger tapping results in robust
activity within cortex surrounding superior lateral
central sulcus in expected somatotopic location for
finger/hand
Complex finger-tapping task broadly activates motor and
premotor regions, including M1, ventral premotor, and
dorsal premotor cortices
• Foot movement
Foot/ankle movement results in robust activity within
cortex about superior termination of central sulcus and
in paracentral lobule
Foot activation along superior (not medial) perirolandic
cortex with medial surface activated by sacral
dermatomes
• Tongue movement/lip puckering
Movement of tongue back and forth within closed mouth
activates lower extent of corticobulbar motor cortex
along homunculus
Lip puckering activates about lateral central sulcus in
expected somatotopic location for lower face
sensorimotor cortex
• Sensory
Stimulation of hands, either unilaterally or bilaterally,
performed with investigator's fingertips or mildly
abrasive device
BOLD activations are located in somatosensory area
– Relative to primary motor area, activation is shifted
laterally for hand and dorsally for foot
representations following morphology of postcentral
gyrus
Sedated/unresponsive patients (e.g., pediatric or
comatose)
Patients lacking motive control of upper limb (e.g.,
neurologic deficit or cerebral palsy)
Preoperative planning ± intraoperative fMRI in
neuronavigation
• Diffusion tensor imaging
Tractography with maximum posteriori probability
classification can effectively retrieve locations of cortical
motor areas and course of corticospinal tracts for
presurgical planning
Corticospinal tracts run in posterior 1/3 of posterior limb
of internal capsule
Image Gallery
Print Images
MOTOR OVERVIEW
3D surface-rendered images (top) and axial MP-RAGE with
blood-oxygen-level dependent (BOLD) overlay (bottom) of a
complex finger-movement task exhibit activation in the motor
cortex and premotor area as well as the supplementary
area.
Resting state fMRI reveals functional connectivity between
the anatomically distinct right and left precentral gyri.
Functional connectivity can be inferred from the temporal
correlation between activity in various regions of the brain,
such as neural connectivity of the primary motor cortex, in
this case.
SOMATOSENSORY HOMUNCULUS
Graphic of lateral cerebral hemisphere (top) shows the
postcentral (blue) and precentral (green) gyri. Coronal
graphic (bottom) reveals the somatosensory representation
in the postcentral gyrus (left) and the motor representation
in the precentral gyrus (right). This somatotopic organization
is also called the homunculus. As the graphic illustrates, the
head representation is more laterally located within the
gyrus, while the feet are more superomedially situated. The
disproportionate area corresponding to the face and hands
reflects the tactile sensation and manual dexterity given to
those areas.
Surface-rendered 3D images with BOLD overlay
demonstrate group-level motor activation with right finger
movement (sequential thumb to each of the other fingers) in
29 subjects.
SENSORIMOTOR NETWORK: FUNCTIONAL ACTIVATION

Colored regions show voxels within the sensorimotor
network cluster from a 6-network brain parcellation based
on functional connectivity in 1,353 subjects. The voxels
within this network were colored based on t-statistics for a
bilateral finger-tapping task in 26 subjects with t-statistic for
activation shown by color. The task-based activation and
functional connectivity parcellation include a similar
distribution of regions.
CEREBELLAR MOTOR REGIONS

Image A shows somatomotor representation from
physiological responses to stimulation of foot, hand, and
face in the right and left cerebral hemispheres. Image B
depicts the cerebral somatomotor topography evoked by
foot, hand, and tongue movements as measured by task
fMRI. Image C shows the inverted somatomotor
topography in the anterior lobe of the contralateral
cerebellum. In image D, the right cerebral seed regions
defined by task activation data are noted. Image E
illustrates the somatomotor map in the cerebellum based on
functional connectivity MRI (fcMRI) with the contralateral
cerebrum. Image F shows sagittal and axial views of
somatomotor representation within the cerebellum.
(Adapted from R. Buckner, 2011.)
Additional Images
Surface anatomy of cerebral hemisphere is seen from

above. Gyri and lobules are shown on the left and the sulci
are shown on right. Central (Rolandic) sulcus separates
posterior frontal lobe from anterior parietal lobe. Precentral
gyrus of the frontal lobe is the primary motor cortex, while
the postcentral gyrus of the parietal lobe is the primary
sensory cortex.
Axial T2 MR (left) with BOLD overlay demonstrates

activation in the precentral gyrus and supplementary
motor area . Similarly, the 3D surface-rendered image
(right) illustrates this activation to be in the "hand knob" with
the finger-tapping task . Initiation of movement elicits
activation in the supplementary motor area .
Selected References
Selected References
1. Wongsripuemtet, J, et al. Preoperative mapping of the
supplementary motor area in patients with brain tumor
using resting-state fMRI with seed-based analysis. AJNR Am
J Neuroradiol. 2018; 39(8):1493–1498.
2. Yahyavi-Firouz-Abadi, N, et al. Presurgical brain mapping
of the ventral somatomotor network in patients with brain
tumors using resting-state fMRI. AJNR Am J Neuroradiol.
2017; 38(5):1006–1012.
3. Hou, BL, et al. Quantitative comparisons on hand motor
functional areas determined by resting state and task BOLD
fMRI and anatomical MRI for pre-surgical planning of
patients with brain tumors. Neuroimage Clin. 2016; 11:378–
387.
4. Jeong, JW, et al. Automatic detection of primary motor
areas using diffusion MRI tractography: comparison with
functional MRI and electrical stimulation mapping.
Epilepsia. 2013; 54(8):1381–1390.
5. Oguri, T, et al. Overlapping connections within the motor
cortico-basal ganglia circuit: fMRI-tractography analysis.
Neuroimage. 2013; 78:353–362.
6. Buckner, RL, et al. The organization of the human
cerebellum estimated by intrinsic functional connectivity. J
Neurophysiol. 2011; 106(5):2322–2345.
7. Liu, H, et al. Task-free presurgical mapping using
functional magnetic resonance imaging intrinsic activity. J
Neurosurg. 2009; 111(4):746–754.
8. Nioche, C, et al. Functional connectivity of the human red
nucleus in the brain resting state at 3T. AJNR Am J
Neuroradiol. 2009; 30(2):396–403.
9. Shimony, JS, et al. Resting-state spontaneous fluctuations
in brain activity: a new paradigm for presurgical planning
using fMRI. Acad Radiol. 2009; 16(5):578–583.
10. Zhang, D, et al. Preoperative sensorimotor mapping in brain
tumor patients using spontaneous fluctuations in neuronal
activity imaged with functional magnetic resonance
imaging: initial experience. Neurosurgery. 2009; 65(6
Suppl):226–236.
11. Bizzi, A, et al. Presurgical functional MR imaging of
language and motor functions: validation with
intraoperative electrocortical mapping. Radiology. 2008;
248(2):579–589.
12. Kavounoudias, A, et al. Proprio-tactile integration for
kinesthetic perception: an fMRI study. Neuropsychologia.
2008; 46(2):567–575.
13. Erberich, SG, et al. Somatosensory lateralization in the
newborn brain. Neuroimage. 2006; 29(1):155–161.
14. Chung, GH, et al. Functional heterogeneity of the
supplementary motor area. AJNR Am J Neuroradiol. 2005;
26(7):1819–1823.
15. Karaarslan, E, et al. Perirolandic cortex of the normal brain:
low signal intensity on turbo FLAIR MR images. Radiology.
2003; 227(2):538–541.
16. Naidich, TP, et al. The parasagittal line: an anatomic
landmark for axial imaging. AJNR Am J Neuroradiol. 2001;
22(5):885–895.
17. Lee, HK, et al. Location of the primary motor cortex in
schizencephaly. AJNR Am J Neuroradiol. 1999; 20(1):163–
166.
18. Meyer, JR, et al. Location of the central sulcus via cortical
thickness of the precentral and postcentral gyri on MR.
AJNR Am J Neuroradiol. 1996; 17(9):1699–1706.
Visual Network
Main Text
IM AGING ANATOM Y
Overview
• Retina → optic nerve → optic chiasm → optic nerve →

lateral geniculate nucleus (LGN) → optic radiations (ORs)
→ visual cortex
• Image on retina is inverted and reversed: Upper visual space
projects onto lower retina, lower visual space projects onto
upper retina
Right visual space projects onto left hemiretina in each
eye, left visual space projects onto right hemiretina in
each eye
Central fixation point falls onto fovea of each retina,
region of highest visual acuity, and represents 1/2 optic
fibers and 1/2 cells in primary visual cortex
Macula surrounds fovea
• Retinal ganglion cells send axons into optic nerve
• Partial crossing of fibers in optic chiasm
Nasal retinal fibers for each eye, responsible for temporal
hemifields, cross at chiasm
• Axons of retinal ganglion cells in optic tracts synapse in
LGN of thalamus
Small number of fibers enter superior colliculus and
pretectal area
Project to brainstem, to lateral parietal cortex, to frontal
eye fields via relays in pulvinar and lateral posterior
nucleus of thalamus
• LGN axons enter OR, which consists of 3 white matter fiber
bundles
Inferior or ventral bundle (Meyer loop) projects from
LGN and runs anteriorly across superior aspect of
anterior tip of temporal horn
– Makes sharp turn to pass posteriorly along wall of
lateral ventricle to converge on lower lip of calcarine
fissure
– Temporal horn described as being 5.0 mm ± 3.9 mm
anterior to Meyer loop
– Most anterior portion of Meyer loop is about 28 mm
from temporal pole
Central bundle leaves LGN in lateral direction and
follows posteriorly along lateral ventricular wall to visual
cortex
Dorsal bundle extends directly posterior to meet upper
part of calcarine cortex
• Visual cortex consumes virtually all of occipital lobe, from
primary sensory areas along calcarine sulcus and occipital
pole through posterior parietal and temporal lobes
Upper lesions → contralateral inferior quadrant defects
Lower lesions → contralateral superior quadrant defects
• Input from primary visual cortex projects to extrastriate
regions of visual association cortex with 2 processing
streams
Dorsal pathway ("where" pathway) extends from V1/V2
to V3 and into medial posterior parietal lobe
– Processes localization of stimuli in space, visual
attention, spatial awareness, coordination of
reaching and grasping
Ventral pathway ("what" pathway) extends from V1/V2
to V4, V5/middle temporal (MT), and anterior inferior
temporal (AIT) lobe
– Processes complex feature detection in visual stimuli,
motion perception, analyzes form, identifies colors,
faces, letters
• Multiple bilateral visual processing areas, each with
complete retinotopic map of visual space [V1, V2, V3, V4,
V5/MT, V6, intraparietal sulcus (IPS) regions]
Multiple additional retinotopic and spatial
attentionotopic maps cover 1/4 of cortex, including
temporal, parietal, and frontal cortex
Primary (Striate) Visual Cortex (V1)
• 1st visual area receiving sensory input in cortex

• Located along margins of calcarine sulcus
• Foveal vision near occipital pole, with more peripheral vision
extending anteriorly
Extrastriate Visual Cortex (V2, V3, V4, V5/MT)
• V2 (Brodmann area 18): Immediately borders V1, with

inverted retinotopic maps
• V3 (Brodmann area 19): Superior and anterior area V2, part
of dorsal stream
Processes progressively more abstract feature extraction
V3A and V3B retinotopic maps
• V4 (Brodmann area 19): Anterior to V2 in lateral occipital
cortex, part of ventral stream
Lateral occipital: LO-1, LO-2 retinotopic maps along
lateral occipital cortex anterior to V3
Ventral occipital, human V4: VO-1, VO-2, hV4
retinotopic maps along inferomedial occipital cortex
anterior to V3
• V5 (Brodmann area 19): MT gyrus at temporooccipital
junction; processes motion, color, and attention perception;
part of ventral stream
• V6 (Brodmann area 19): Along parietooccipital sulcus
(medial motion area, analogue to primate mediodorsal
area), part of dorsal stream
Lateral Geniculate Nuclei of Thalamus
• Visualized on axial slice through superior colliculus at

posterior lateral margin of thalamus
• Endpoint of optic tracts
• Postsynaptic fibers extend anteromedial along Meyer loop,
then posteriorly along ORs through visual cortex
• Additional fibers likely extend through lingual gyrus of
occipital lobe to reach primary visual cortex layer 4
Intraparietal Sulcus (IPS0/V7, IPS1, IPS2, IPS3, IPS4)
• Posterior parietal regions processing stimulus attention

• Visual attentional regions along medial aspect of IPS
• Multiple areas with complete retinotopic map of visual
space (IPS0, IPS1, IPS2, IPS3, IPS4)
Frontal Eye Fields
• Control direction of attention and eye movements to salient

targets
• Supplementary eye fields involved in control of saccadic eye
movements
• Topographic connections with IPS and MT regions involved
in attentional control across visual, auditory,
somatosensory, and cognitive stimuli
Dedicated Complex Visual Form Areas

• Fusiform face area processes facial recognition in inferior
temporal cortex
• Parahippocampal place area processes recognition of
specific buildings, landmarks, and visual scenes
• Extrastriate body area specific to identification of body parts
• Selective region for identifying tools in occipitotemporal
cortex
• Specific regions involved in processing letters, numbers, and
words

• Will see visual cortex activation in language-reading and

picture-naming tasks
• fMRI retinotopic mapping provides detailed information
about correspondence between visual field and its cortical
representation in individual subject
Localizes functional imaging data with respect to
functional architecture of visual system
Demonstrates retinotopic properties of visual areas in
healthy and impaired brain
"Visual stimulation task" can be performed by showing
checkerboards during active period and blank screen
during rest period
Expanding ring or annular stimuli allow for
characterization of visual eccentricity (central vs.
peripheral visual field)
Rotating stimuli allow characterization of visual angle
and can be used to identify primary visual cortical (V1)
and extrastriate visual cortical (V2/V3) boundaries
• Diffusion tensor tractography can identify optic nerves,
chiasm, and ORs, including Meyer loop
Imaging Pitfalls
• Should check visual acuity prior to fMRI visual field

mapping
• Extensive individual variation in extrastriate regional
anatomy
• Multiple overlapping functional roles for more complex
extrastriate regions such as V5/MT, fusiform face area, IPS
Clinical Importance
• Vascular loops (P1 segment) can compress optic tracts and

result in otherwise unexplained quadrantanopsia
• Presurgical visual field mapping usually focused on
preserving V1/V2 retinotopic maps and foveal vision, ORs
• DTI best for imaging course of ORs for presurgical mapping
• Lesions in optic chiasm → bitemporal visual field defects
• Lesions of eye, retina, optic nerve → monocular visual field
defects
• Lesions of optic tracts, LGN, or visual cortex →
homonymous visual field defects
• Complication of anterior temporal lobectomy: Visual field
deficit due to disruption of ORs, specifically anterior bundle
of Meyer loop
Image Gallery
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VISUAL PATHWAY
Graphic of optic radiations (ORs) illustrates the inferior or
ventral bundle (Meyer loop), central bundle, and dorsal
bundle. The Meyer loop makes a wide anterior and lateral
loop around the temporal horn of the lateral ventricle before
curving around the posterior atrium to reach the occipital
cortex. These inferior fibers may pass into the uncinate
region of the temporal lobe and contribute to the uncinate
fascicle located at the limen insula or temporal stem. The
upper and central bundles pass through the parietal and
high temporal lobes, respectively, to synapse in the primary
visual cortex. The upper fibers carry information from the
superior quadrants of the retina; the lower fibers carry
information from the inferior quadrants of the retina. The
central bundle contains macular fibers (central area of the
retina).
VISUAL CORTEX AND OPTIC RADIATIONS
The visual network cluster is shown from a 6-network

parcellation of the brain based on whole-brain functional
connectivity in 1,353 subjects. Regions within this cluster
include striate and extrastriate visual cortex, medial parietal
visual attentional regions, and lateral geniculate nuclei of the
thalamus.
Axial DTI fractional anisotropy color maps illustrate the OR
fibers, which are predominantly anteroposteriorly oriented.
False-positive tracts that are not part of the tract of interest
can be generated, such as when the anterior projections
from the OR may actually reflect the inferior occipitofrontal
fibers. Voxel size used in DTI can be between 1 and 3 mm³,
but an axon measures ~ 0.01 mm. Therefore, the signal
from 1 voxel represents thousands of axons that may have
different directions.
VISUAL FIELD MAPPING

Rotating hemifield stimulus used for visual field mapping is
shown. A hemifield checkerboard stimulus (or wedge)
rotates around the visual field while the subject focuses the
eyes on the center of the image. The timing of activation in
the brain allows creation of an angular map of visual space.
Expanding ring stimulus used for visual field eccentricity
mapping is shown. The stimulus gradually expands from the
center of the visual field while the subject focuses the eyes
on the center of the image. The timing of activation in the
brain allows creation of a map of visual stimulus
eccentricity.
VISUAL HEMIFIELDS
Angular map of visual space is shown with colors in the
circle representing the corresponding part of visual space
associated with each region of the visual cortex. Left visual
space is processed in the right visual cortex and right visual
space is processed in the left visual cortex, with inversion of
the superior visual field in the primary visual cortex inferior
to calcarine sulcus, with inferior visual field processed by
cortical regions superior to the calcarine sulcus.
VISUAL ECCENTRICITY MAPS

Map of visual field eccentricity is shown. The colored circle
represents a map of visual space. The center of visual
space, foveal vision, is represented at the occipital pole of
the primary visual cortex, with more peripheral vision
processed anteriorly in the visual cortex.
Visual field map based on eccentricity of visual stimuli is
shown. The colored circle represents a map of visual space
with fMRI images showing activation corresponding to
stimuli at each stimulus eccentricity.
VISUAL CORTEX SUBREGIONS

Visual processing areas (V1, V2, V3, V4, V5/MT, V6,
intraparietal sulcus regions) each have a complete
retinotopic map of visual space, and each is largely
dependent on the primary visual cortex for its activation.
Extrastriate cortical areas project to temporal and parietal
cortical association areas. The ventral stream, including V4,
leads from V1 into the inferior temporal lobe and is
responsible for high-resolution form vision and object
recognition. The dorsal stream, including the middle
temporal (MT), leads from V1 into the parietal lobe and is
responsible for the analysis of motion and positional
relationships between objects in the visual scene.
These visual processing areas are specialized for different
aspects of the visual scene. MT neurons respond to the
direction of a moving edge without regard to its color.
Neurons in area V4 respond to the color of a visual stimulus
without regard to its direction of movement. Lateral occipital
areas 1 (LO1) and 2 (LO2) contain a topographic
representation of the contralateral visual hemifield,
integrating shape information from multiple visual
submodalities in retinotopic coordinates.
Selected References
1. Killian, NJ, et al. Grid cells map the visual world. Nat
Neurosci. 2018; 21(2):161–162.
2. Deen, B, et al, Organization of high-level visual cortex in
human infants. Nat Commun 2017; 8 13995
3. Fairhall, SL, et al. Spatiotopic updating across saccades
revealed by spatially-specific fMRI adaptation. Neuroimage.
2017; 147:339–345.
4. Griffis, JC, et al. Retinotopic patterns of functional
connectivity between V1 and large-scale brain networks
during resting fixation. Neuroimage. 2017; 146:1071–1083.
5. Iacaruso, MF, et al. Synaptic organization of visual space in
primary visual cortex. Nature. 2017; 547(7664):449–452.
6. Mackey, WE, et al. Visual field map clusters in human
frontoparietal cortex. Elife. 6, 2017.
7. Smith, IT, et al. Stream-dependent development of higher
visual cortical areas. Nat Neurosci. 2017; 20(2):200–208.
8. Striem-Amit, E, et al. Sensorimotor-independent
development of hands and tools selectivity in the visual
cortex. Proc Natl Acad Sci U S A. 2017; 114(18):4787–4792.
9. Weiner, KS, et al. The cytoarchitecture of domain-specific
regions in human high-level visual cortex. Cereb Cortex.
2017; 27(1):146–161.
10. Ko, H, et al. The emergence of functional microcircuits in
visual cortex. Nature. 2013; 496(7443):96–100.
11. Baldassarre, A, et al. Individual variability in functional
connectivity predicts performance of a perceptual task. Proc
Natl Acad Sci U S A. 2012; 109(9):3516–3521.
12. Gaglianese, A, et al. Evidence of a direct influence between
the thalamus and hMT+ independent of V1 in the human
brain as measured by fMRI. Neuroimage. 2012; 60(2):1440–
1447.
13. Mandelstam, SA. Challenges of the anatomy and diffusion
tensor tractography of the Meyer loop. AJNR Am J
Neuroradiol. 2012; 33(7):1204–1210.
14. Pietrasanta, M, et al, The corpus callosum and the visual
cortex: plasticity is a game for two. Neural Plast 2012; 2012
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default or frontal-parietal network based on goals. Nat
Neurosci. 2011; 14(7):830–832.
16. Wandell, BA, et al. Imaging retinotopic maps in the human
brain. Vision Res. 2011; 51(7):718–737.
17. Wendt, J, et al. The functional connectivity between
amygdala and extrastriate visual cortex activity during
emotional picture processing depends on stimulus novelty.
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19. Zou, Q, et al. Functional connectivity between the thalamus
and visual cortex under eyes closed and eyes open
conditions: a resting-state fMRI study. Hum Brain Mapp.
2009; 30(9):3066–3078.
20. Saygin, AP, et al. Retinotopy and attention in human
occipital, temporal, parietal, and frontal cortex. Cereb Cortex.
2008; 18(9):2158–2168.
21. Sherbondy, AJ, et al. Identifying the human optic radiation
using diffusion imaging and fiber tractography. J Vis. 2008;
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22. Shmuel, A, et al. Neuronal correlates of spontaneous
fluctuations in fMRI signals in monkey visual cortex:
implications for functional connectivity at rest. Hum Brain
Mapp. 2008; 29(7):751–761.
23. Yacoub, E, et al. High-field fMRI unveils orientation
columns in humans. Proc Natl Acad Sci U S A. 2008;
105(30):10607–10612.
24. Wandell, BA, et al. Visual field maps in human cortex.
Neuron. 2007; 56(2):366–383.
25. Yacoub, E, et al. Robust detection of ocular dominance
columns in humans using Hahn Spin Echo BOLD
functional MRI at 7 Tesla. Neuroimage. 2007; 37(4):1161–
1177.
26. Nir, Y, et al. Widespread functional connectivity and fMRI
fluctuations in human visual cortex in the absence of visual
stimulation. Neuroimage. 2006; 30(4):1313–1324.
27. Astafiev, SV, et al. Extrastriate body area in human occipital
cortex responds to the performance of motor actions. Nat
Neurosci. 2004; 7(5):542–548.
28. Hampson, M, et al. Changes in functional connectivity of
human MT/V5 with visual motion input. Neuroreport. 2004;
15(8):1315–1319.
29. Sereno, MI, et al. Borders of multiple visual areas in humans
revealed by functional magnetic resonance imaging. Science.
1995; 268(5212):889–893.
Limbic Network
Main Text
IM AGING ANATOM Y
Overview
• Limbic network includes amygdala, striatum, orbitofrontal

cortex, insula, medial temporal lobe, and claustrum
Amygdala
• Differential connectivity patterns for laterobasal,

centromedial, and superficial amygdala, similar to animal
studies
Laterobasal amygdala has greatest connectivity to frontal
and temporal limbic areas
Centromedial amygdala has greatest connectivity to
striatum
Diffuse connectivity of superficial amygdala throughout
limbic system
Striatum (Caudate, Putamen, Nucleus Accumbens, Olfactory

Tubercle)
• Dorsal vs. ventral division sometimes drawn at caudate and

putamen (dorsal) vs. nucleus accumbens and olfactory
tubercle (ventral)
Dorsoventral functional gradients are gradual without
clear dividing line
• Dorsolateral striatum
More associated with sensorimotor function, procedural
learning
Connectivity to dorsal prefrontal cortex, motor cortex,
sensory cortex
• Ventromedial striatum
More associated with reward processing, reinforcement,
and appetitive control
Connectivity to limbic structures: Cingulate, orbitofrontal
cortex, amygdala
Orbitofrontal Cortex
• Connectivity to medial temporal lobe structures via uncinate

fasciculus
• Shared with ventral attention network
• Involved in response inhibition, executive control, affective
cognition
Insula
• Inferior insula shows greatest connectivity to medial

temporal lobe
• Superior insula shows greatest connectivity to cingulate
cortex and dorsal striatum (merges with salience network)
Parahippocampal Cortex
• Involved in processing of memory, navigation, and affective

cognition
• Hippocampal formation shared with default mode network
Claustrum
• Function largely unknown, possible role in interhemispheric
coordination
• Connectivity to hippocampus, amygdala, dorsal striatum

• Imaging of regions of high susceptibility in orbitofrontal and

medial temporal regions may be improved by oblique planes
that avoid bone interfaces, higher resolution, multiband
BOLD pulse sequences, and parallel imaging
Imaging Pitfalls
• Limbic network, as defined by functional connectivity, may

include regions of high magnetic susceptibility with less
precise functional boundaries
• Includes major arterial inflow territories, which may also
result in image artifacts associated with vascular influences
on functional connectivity
Clinical Importance
• Major depression: Hyperactivity of pregenual anterior

cingulate, limbic network
• Affective control: Disorders of orbitofrontal cortex
associated with impulsivity, multiple psychiatric disorders
• Addiction: Proposed abnormalities of mesolimbic circuits
regulating reward and reinforcement
• Autoimmune limbic encephalitis: Paraneoplastic condition
affecting primarily medial temporal lobes
• Herpes encephalitis: Predilection for medial temporal and
limbic regions
• Epilepsy: Limbic regions often show increased FLAIR signal
following generalized seizures or status epilepticus
Image Gallery
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LIMBIC NETWORK
Limbic network is shown from a 6-network parcellation of

the brain from 1,353 subjects. This network is a composite
of 13 components generated by an infomap algorithm from
18 components and represents the least homogeneous of
the brain networks. The network includes areas in regions
of high susceptibility artifact, near the circle of Willis, and
involving deep gray nuclei. Nevertheless, this cluster also
includes regions in the medial temporal lobe and limbic
system thought to have underlying anatomic connectivity.
Regions of high magnetic susceptibility are shown in pink,

generated from a separately acquired field map and
overlaid on a structural MP-RAGE sequence. Image was
generated with Neuro3D software (Siemens). Areas of high
susceptibility show high overlap with the limbic network,
suggesting that some of the correlation in this network may
be defined by image artifacts from poor BOLD signal.
Additional Images
Limbic network is shown from a 6-network parcellation of

the brain from 1,353 subjects. This network is a composite
of 13 components generated by an infomap algorithm from
18 components and represents the least homogeneous of
the brain networks, with likely contributions from image
artifacts. The network includes areas in regions of high
susceptibility artifact, near the circle of Willis, and involving
deep gray nuclei. Nevertheless, this cluster also includes
many regions in the medial temporal lobe and limbic system
that are thought to have underlying anatomic connectivity.
Selected References
1. Arnold Anteraper, S, et al. Resting-state functional
connectivity of the subthalamic nucleus to limbic,
associative, and motor networks. Brain Connect. 2018;
8(1):22–32.
2. Golchert, J, et al. Individual variation in intentionality in the
mind-wandering state is reflected in the integration of the
default-mode, fronto-parietal, and limbic networks.
Neuroimage. 2017; 146:226–235.
3. Smith, JB, et al. Rat claustrum coordinates but does not
integrate somatosensory and motor cortical information. J
Neurosci. 2012; 32(25):8583–8588.
Neurophysiol. 2011; 106(3):1125–1165.
5. Roy, AK, et al. Functional connectivity of the human
amygdala using resting state fMRI. Neuroimage. 2009;
45(2):614–626.
6. Greicius, MD, et al. Resting-state functional connectivity in
major depression: abnormally increased contributions from
subgenual cingulate cortex and thalamus. Biol Psychiatry.
2007; 62(5):429–437.
7. Heimer, L, et al. The limbic lobe and its output channels:
implications for emotional functions and adaptive behavior.
Neurosci Biobehav Rev. 2006; 30(2):126–147.
8. Postuma, RB, et al. Basal ganglia functional connectivity
based on a meta-analysis of 126 positron emission
tomography and functional magnetic resonance imaging
publications. Cereb Cortex. 2006; 16(10):1508–1521.
9. Anand, A, et al. Activity and connectivity of brain mood
regulating circuit in depression: a functional magnetic
resonance study. Biol Psychiatry. 2005; 57(10):1079–1088.
10. Morgane, PJ, et al. A review of systems and networks of the
limbic forebrain/limbic midbrain. Prog Neurobiol. 2005;
75(2):143–160.
11. Voorn, P, et al. Putting a spin on the dorsal-ventral divide of
the striatum. Trends Neurosci. 2004; 27(8):468–474.
Language Network
Main Text
T ERM INOLOGY
Definitions
• Receptive language: Perception of spoken or written

language
• Expressive language: Generating words and producing
spoken language
• Broca aphasia: Inability to speak, word-finding difficulty,
poor speech fluency, inability to organize grammar
• Wernicke aphasia: Inability to comprehend speech
IMAGING ANATOMY
Overview
• Language involves complex network of frontal, parietal, and

temporal regions; typically left hemisphere dominant
• Bilaterality or right dominance of language in 5% of right-
handed and 22% of left-handed or ambidextrous individuals
• Higher incidence of bilaterality or right dominance in
psychiatric and developmental disorders, including autism
and schizophrenia
• Core regions for presurgical mapping are Broca area,
Wernicke area, supplementary motor area (SMA), and
lateral premotor (Exner) area; injury of many other areas
may produce more subtle language deficits
Broca Area
• Posterior left inferior frontal gyrus bordering operculum

(Brodmann areas 44, 45): Pars opercularis and pars
triangularis
• Primary locus of expressive language, creating syntax, and
production of meaningful language
• Overlapping spatial distribution of syntax, phonology, and
grammar-processing subregions
• Word selection processed more anteriorly, articulatory
planning more posteriorly
Wernicke Area
• Posterior superior temporal gyrus, posterior superior

temporal sulcus, and posterior middle temporal gyrus
(posterior Brodmann area 22)
• Primary locus of receptive language, phonological
processing, and speech perception
• Semantic meaning also processed in adjacent angular,
supramarginal, and middle temporal gyri
Lateral Premotor Cortex (Exner Area)
• Extends posterior and superior from Broca area anterior to

precentral sulcus (Brodmann area 6)
• Primary locus for writing language
• Required to plan motor representations associated with
speech or writing
Supplementary Motor Area
• Posterior medial superior frontal gyrus near vertex (medial

Brodmann area 6)
• Language SMA (pre-SMA) directly anterior to motor SMA
• Injury can cause severe language deficits that improve or
resolve over weeks
Dorsolateral Prefrontal Cortex
• Middle frontal gyrus, anterior and superior to Broca area

(Brodmann area 46)
• Processing of complex semantic, analytical, and abstract
concepts during language
• Stores autobiographical knowledge of self, objects, people,

events, culture; processes internal narrative
• Interfaces with core language regions to process contextual
meaning of language
• Distributed network, including angular gyrus
(temporoparietal junction), posterior cingulate (precuneus),
medial prefrontal cortex, middle and inferior temporal gyri
• Connections between default mode network and core
language areas are left lateralized
• Focal lesions typically do not produce aphasia
• Default mode regions not activated on most fMRI language
tasks
Auditory Cortex
• Superior temporal gyrus, including Heschl gyrus (Brodmann

areas 41, 42)
• Between Broca and Wernicke areas on axial slices
• Surrounded by auditory association cortex for progressively
higher level auditory perception
• Auditory/motor integration in posterior temporoinsular
junction often activated by language tasks
Visual Cortex
• Primary visual cortex (V1): Pericalcarine occipital pole

(Brodmann area 17)
• Secondary visual cortex (V2, V3, V4, V5/MT, Brodmann
areas 18 and 19) surrounds V1
• Lingual occipital gyrus and lateral occipital cortex:
Recognition and processing of written letters and symbols
• Inferior lateral temporooccipital cortex and angular gyrus
both involved in reading
Accessory Inferior Temporal and Occipital Language Regions
• Basal temporal language area (BTLA) (a.k.a. visual word

form area) has been proposed in mid-left fusiform gyrus
• Likely not specific to language but may be involved in letter
and word recognition
• No permanent severe language deficits expected from
unilateral BTLA injury
• Lingual gyrus more associated with global shape processing
of letters; fusiform gyrus associated with local shape
processing of letters
Cerebellar Language Regions
• Inferior vermis and posterior paramedial cerebellar

hemisphere
• Typically right dominant for language
• Subtle high-level impairments in language when injured or
resected
Basal Ganglia
• Variable activation of caudate and putamen on language
tasks
• Lesions typically do not cause aphasia
Arcuate Fasciculus White Matter Pathway (Dorsal Stream)
• Ascends anterosuperior from Wernicke area, then anteriorly

along superior longitudinal fasciculus to lateral premotor
regions
• Dominant white matter tract connecting temporal receptive
language areas to expressive premotor language regions
• Carries information required for repetition of speech
Extreme Capsule White Matter Pathway (Ventral Stream)
• Connects Wernicke area and Broca area to auditory cortex,

associating sounds of speech to meanings
• Distinct pathway from external capsule (corticostriatal
projections) and uncinate fasciculus (limbic connections of
amygdala and hippocampus to cortex)

• Use at least 2 or 3 different language tasks to avoid false-

negative results
• Target receptive (Wernicke area) vs. expressive (Broca area)
language by task selection based on lesion location or
symptoms
• Receptive language tasks
Passive listening: Subjects listen to speech vs. silence or
scrambled speech
Passive reading: Subjects read sentences vs.
pseudowords or unfamiliar languages
• Expressive language tasks
Object naming: Subjects think in their minds names of
objects shown in picture stimuli
Silent word generation: Subjects think of words that
begin with given letter
• Combined language tasks
Response naming: Subjects think answer of multiple
choice question
Phrase recognition: Subjects think word that describes
verbal or written phrase
Sentence completion: Subjects read sentence and think
of word that would complete sentence
Semantic decision: Subjects are presented with 2 words
(e.g., "fruit" and "apple") and push button if categorically
related
Rhyming: Subjects press button if 2 presented words
rhyme
Imaging Pitfalls
• Poor task performance may explain false-negative results

(train subjects on task before scan)
Language Lateralization
• Incidence of right-dominant or bilateral language laterality

in healthy individuals is 4-6%
• In left-handed individuals, 8% have right-dominant
language and 14% show bilaterally symmetric language on
fMRI
• Higher bilaterality of language (33%) in temporal lobe
epilepsy population
• Higher bilaterality of language in autism, schizophrenia, and
other psychiatric and developmental conditions
• Language laterality increases between ages 5-20 years and
may decrease in older adults
• Correlation with Wada test is high (90%) but may be lower
in left temporal lobe epilepsy (73%)
• Language becomes increasingly bilateral with task difficulty
and atypical task features (emotive content, abnormal
prosody, music)
• Qualitative (expert judgment) assessment may have lower
inter-rater reliability (kappa < 0.7) that can be improved by
adding quantitative metrics, such as laterality index for
whole brain or specific regions
Multilingual Individuals
• Different languages may have overlapping, adjacent

territories in Broca and Wernicke areas
Sign Language Speakers (Hearing Impaired)
• Sign perception typically processed adjacent to Wernicke

area
• May have contralateral dominance if brain injury in
dominant hemisphere prior to learning sign language
Right-Hemispheric Language Region Homologues
• Nondominant hemisphere regions are recruited for more

difficult language tasks
• Increasingly active when language involves atypical
prosody, music, context, or rhythm
Crossed Hemispheric Dominance
• May have left-dominant receptive with right-dominant

expressive language regions or vice versa
Typically occurs with slow-growing lesions in dominant
hemisphere
Language regions close to lesion may have function
subsumed by contralateral hemisphere
Role of Wada Test
• Can be helpful in cases of symmetric bilateral hemisphere

language activation or poor/atypical activation on fMRI
May simulate deficit if 1 hemisphere is inactivated
• Concordant dominance with fMRI > 90%
• Wada not as effective at quantifying crossed hemisphere
dominance or bilateral activation
• Wada is 3.7x more expensive and invasive with risk of
dissection, stroke, and hemorrhage
• May be needed for arteriovenous malformations in which
false-negative results are more common
Image Gallery
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RENDERED AC TIVATION: SPOKEN AND WRITTEN
LANGUAGE
Auditory language: fMRI activation is shown during an
auditory phrase-recognition task, averaged across images
from 40 healthy volunteers. The task was a block design in
which active blocks consisted of listening to phrases, such
as "the funny guys at the circus," and rest blocks consisted
of no speech with only ambient MR scanner sounds. During
active blocks, volunteers were instructed to think but not
speak aloud a word that the phrase described. Color bars
show relative activation (T-score, range: 4-12).
Visual language: fMRI activation is shown during a visual
sentence-completion task, averaged across images from 25
healthy volunteers. The task was a block design in which
active blocks consisted of reading sentences with a blank at
the end (e.g., "He put the dishes in the _______.") and rest
blocks consisted of visual fixation on a + sign in the center
of the screen. During active blocks, volunteers were
instructed to think but not speak aloud a word that could
complete the sentence.
AUDITORY LANGUAGE (SLIC ES), WHITE MATTER

PATHWAYS
Auditory language: fMRI activation is shown during an
auditory phrase-recognition task, averaged across images
from 40 presurgical patients. The task was a block design
in which active blocks consisted of listening to phrases,
such as "the funny guys at the circus," and rest blocks
consisted of scrambled speech. During active blocks,
volunteers were instructed to think but not speak aloud a
word that the phrase described. Color bar shows relative
activation (T-score).
White matter tracts of the ventral language pathway are
shown. Fiber tracts include the extreme capsule and
pathways between superior temporal, inferior frontal, and
angular gyrus language and semantic regions. The ventral
pathway is the core backbone underlying language
comprehension networks.
White matter tracts of the dorsal language pathway are
shown. Fiber tracts include the arcuate fasciculus between
lateral inferior frontal, premotor, and superior temporal
language regions. The dorsal pathway participates in
repetition of language, motor articulatory planning for
speech, and working memory for language.
Selected References
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language fMRI. Neuroimage. 2018; 176:215–225.
2. Black, DF, et al. American Society of Functional
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alternative to task-based language fMRI and its laterality
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language lateralization: an additional diagnostic feature for
assessing atypical language representation in presurgical
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5. Sreedharan, RM, et al. Arcuate fasciculus laterality by
diffusion tensor imaging correlates with language laterality
by functional MRI in preadolescent children.
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6. Centeno, M, et al. Language dominance assessment in a
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perspective and review. Cortex. 2010; 46(7):858–868.
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88.
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and ambidextrous people: fMRI data. Neurology. 2002;
59(2):238–244.
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functional magnetic resonance imaging. J Neurosci. 1997;
17(1):353–362.
Memory Network
Main Text
T ERM INOLOGY
Definitions
• Procedural memory: Long-term memory that does not

require conscious recollection, such as motor skills, also
called implicit memory
• Declarative memory: Long-term memory that requires
conscious recollection, can be episodic or semantic, also
called explicit memory
• Episodic memory: Recollection of events or objects related to
specific context, place, or time, includes autobiographical
memory
• Semantic memory: Recollection of facts, ideas, and
knowledge independent of context
• Short-term (working) memory: Form of attention mediated
by distinct neural substrates from those used in long-term
memory; allows rehearsal, recall, and conscious perception
of representations over minutes to hours
• Consolidation: Transfer of sensory or semantic
representations to long-term memory (encoding)
• Pattern separation: Ability to discriminate among
representations of similar experiences or objects
• Pattern completion: Ability to associate representations of
similar experiences or objects
IMAGING ANATOMY
Overview
• Long-term declarative memories thought to be stored in

synaptic strengths and connection patterns in sensory and
association cortex, likely within same regions that process
related perception (visual cortex stores visual memories)
• Hippocampal formation and parahippocampus act as unit
to encode long-term memories in cortex
Anterior parahippocampal gyrus includes entorhinal
(medial) and perirhinal (lateral) cortex
Posterior parahippocampal gyrus and medial fusiform
gyrus compose parahippocampal cortex
• REM sleep facilitates memory consolidation
Hippocampus
• Key structure that processes encoding and retrieval of

declarative memories
• Also involved in navigation, location recognition, and
encoding of spatial memories
• Information flow: Dentate gyrus to CA3 to CA1 to
subiculum
• Perforant path: Entorhinal cortex to each hippocampal
subfield (dentate gyrus, CA3, CA1, subiculum)
• Subiculum axons project to nucleus accumbens, prefrontal
cortex, hypothalamus, entorhinal cortex, and amygdala
• Dentate gyrus required for distinguishing similar
representations (pattern separation)
Parahippocampal Cortex
• Receives strongest inputs from medial parietal cortex

• Outputs to CA1, subiculum, amygdala, entorhinal, and
perirhinal cortex
• Parahippocampal place area: Required for recognizing
places and scenes
Entorhinal Cortex
• Medial entorhinal cortex contains directionally oriented,

topographic map of spatial environment
• Receives inputs from neocortex (all sensory modalities):
Primary gateway from neocortex to hippocampus
• Projections to CA1, CA3, dentate gyrus, and subiculum of
hippocampus
Perirhinal Cortex
• Receives strongest inputs from unimodal visual cortex and

also receives auditory, somatosensory, and polymodal
inputs
• Projections to CA1, subiculum, amygdala, thalamus, basal
ganglia
Amygdala
• Situated immediately lateral to uncus

• Involved in processing emotional salience and memory
formation, particularly poignant emotions, such as fear and
rage
• Extensive connectivity to medial temporal lobe, orbitofrontal
cortex, hypothalamus, and striatum
• Bilateral amygdalar damage leads to Klüver-Bucy syndrome
Fornix
• Arises from hippocampus (subiculum and entorhinal cortex)
and contains subregions: Fimbria, crus, commissure, body,
and pillars (or columns)
• Injury to fornix can cause severe anterograde memory
deficits; use DTI to identify for surgical planning
• Terminates in mammillary bodies of hypothalamus
• Signal abnormalities can be seen with dysfunction
associated with Wernicke encephalopathy
• Likely represents primary site for long-term storage of

semantic memories
• Strong left-dominant connections between default mode
hubs (posterior cingulate, medial prefrontal, inferior
parietal, inferior temporal) to language regions and medial
temporal lobe
Cerebellum
• Involved in procedural memory (motor learning) formation

and classical conditioning
Basal Ganglia
• Involved in procedural memory (skills and habits)
Clinical Importance
• Memory lateralization
Hippocampal activation bilaterally symmetric for
autobiographical memory
Slight left dominance for verbal memory; right
dominance for visuospatial memory
• Medial temporal epilepsy
Memory deficits common after medial temporal
lobectomy but mitigated by function in contralateral
medial temporal lobe
– Severe amnesia with bilateral hippocampal injury
Both long-term recall and new memory formation can be
impaired
Medial temporal epilepsy patients have weaker
ipsilesional, stronger contralesional hippocampal
activation
– Postoperative memory deficit severity weakly
associated with strength of activation in ipsilateral
hippocampus on autobiographical memory tasks
(stronger contralesional activation implies less
deficit after lobectomy)
Functional connectivity between hippocampus and
posterior cingulate (default mode network) stronger in
contralesional side in temporal lobe epilepsy
– Stronger contralesional hippocampal to posterior
cingulate (PCC) connectivity predicts better
prognosis following lobectomy
– Requires comparison to age-matched controls
acquired on same scanner and pulse sequence
Because of limited prognostic information on
postoperative deficits, presurgical fMRI mapping of
memory is not widely practiced but may help predict
memory deficit after temporal resection
– Hippocampal-PCC connectivity appears promising
as predictive biomarker but may require more
sophisticated analysis, normed control data, and
additional validation before clinical implementation
– Wada test may also be used to predict postoperative
memory deficits
– Recent work suggests possible role for lateralization
of memory function prior to temporal lobe resection
(Sidhu et al 2015)
• Dementia
Asymmetric hippocampal atrophy relative to remaining
brain atrophy is biomarker with Alzheimer-type
dementia but with limited sensitivity and specificity
– Hippocampal segmentation and comparison of
volumes to age-matched controls adds some
predictive information for Alzheimer disease
– Secondary atrophy in parietal lobes, temporal lobes,
and eventually frontal lobes is also common
(greatest in default mode network regions)
– Similar regions show decreased uptake on PET
imaging and decreased functional connectivity in
Alzheimer disease
Asymmetric atrophy of frontal lobes relative to other
lobes suggests frontotemporal lobar degeneration
Atrophy of superior parietal lobes > medial temporal
lobes associated with antiphospholipid antibody
syndrome
Atrophy of anterior temporal poles associated with
semantic dementia; atrophy of periopercular region
(especially in left hemisphere) associated with
progressive nonfluent aphasia; atrophy of brainstem
associated with multisystem atrophy
Functional Imaging Tasks
• Autobiographical recall
Block design: Subjects recall event from their life during
"on" blocks; subjects perform control task not involving
episodic memory recall, such as sentence completion
during "off" blocks
Need at least 20 blocks to reliably obtain hippocampal
activity (10 minutes of imaging)
• Semantic recall
Block design: Patients view pictures of objects and
classify as "living" or "nonliving" during "on" blocks;
subjects perform control task, such as comparing 2
abstract designs during "off" blocks
5-minute task, can be repeated for increased signal
• Pattern separation
Event or block design: Patients view series of pictures of
objects and classify them as novel or familiar
May require high-resolution temporal imaging to resolve
hippocampal subfields at expense of obtaining whole-
brain images
Image Gallery
Print Images
LIMBIC AND MEDIAL TEMPORAL ANATOMY
Graphic shows 4 coronal slices from anterior (top left) to
posterior (bottom right). The expected locations of the
olfactory tubercle, piriform cortex, amygdala, hippocampal
subfields (CA1, CA3, dentate gyrus, subiculum), entorhinal
cortex, perirhinal cortex, and parahippocampal cortex are
shown in the left hemisphere by shaded regions.
Graphic of the medial temporal lobe and limbic anatomy
shows the fornix, hippocampal formation, and
parahippocampus. The parahippocampal gyrus extends
posteriorly where it merges with the retrosplenial cingulate
gyrus.
MEDIAL TEMPORAL MR ANATOMY

Anterior coronal true IR slice through the medial temporal
lobe shows bilateral amygdala, just lateral to the uncus. The
amygdala is close to the anterior and mid insular cortex and
is connected to the orbitofrontal cortex via the uncinate
fasciculus. The amygdala is connected to the hypothalamus
via the stria terminalis. Not visible by MR are subnuclei of
the amygdala: Basolateral complex (basal, lateral, and
accessory basal nuclei), central nucleus, medial nucleus,
and cortical nucleus.
Coronal true IR slice through the head of the hippocampus
shows expected locations of hippocampal subfields (dentate
gyrus, CA1, CA3, subiculum). CA2 and CA4 are small
subfields between CA1 and CA3 and between CA3 and
dentate gyrus and are not labeled in the image. The
entorhinal cortex extends from subiculum to halfway up the
medial bank of the collateral sulcus, with perirhinal cortex
along the distal medial and lateral bank of the collateral
sulcus.
True IR posterior coronal slice shows the tail of the
hippocampus and parahippocampal cortex.
Selected References
1. Parvizi, J, et al. Memory, numbers, and action decision in
human posterior parietal cortex. Neuron. 2018; 97(1):7–10.
2. Vahdat, S, et al. Network-wide reorganization of
procedural memory during NREM sleep revealed by fMRI.
Elife. 6, 2017.
3. Sidhu, MK, et al. Memory network plasticity after temporal
lobe resection: a longitudinal functional imaging study.
Brain. 2016; 139(Pt 2):415–430.
4. Gilmore, AW, et al. A parietal memory network revealed by
multiple MRI methods. Trends Cogn Sci. 2015; 19(9):534–
543.
5. Sidhu, MK, et al. Memory fMRI predicts verbal memory
decline after anterior temporal lobe resection. Neurology.
2015; 84(15):1512–1519.
6. Towgood, K, et al. Bringing memory fMRI to the clinic:
comparison of seven memory fMRI protocols in temporal
lobe epilepsy. Hum Brain Mapp. 2015; 36(4):1595–1608.
7. McCormick, C, et al. Default mode network connectivity
indicates episodic memory capacity in mesial temporal lobe
epilepsy. Epilepsia. 2013; 54(5):809–818.
8. Rugg, MD, et al. Brain networks underlying episodic
memory retrieval. Curr Opin Neurobiol. 2013; 23(2):255–260.
9. Shapira-Lichter, I, et al. Portraying the unique contribution
of the default mode network to internally driven mnemonic
processes. Proc Natl Acad Sci U S A. 2013; 110(13):4950–
4955.
10. Bonelli, SB, et al. Imaging language networks before and
after anterior temporal lobe resection: results of a
longitudinal fMRI study. Epilepsia. 2012; 53(4):639–650.
11. Centeno, M, et al. Memory in frontal lobe epilepsy: an fMRI
study. Epilepsia. 2012; 53(10):1756–1764.
12. Sestieri, C, et al. Episodic memory retrieval, parietal cortex,
and the default mode network: functional and topographic
analyses. J Neurosci. 2011; 31(12):4407–4420.
13. St Jacques, PL, et al. Dynamic neural networks supporting
memory retrieval. Neuroimage. 2011; 57(2):608–616.
14. Thomas, AG, et al. The fornix in health and disease: an
imaging review. Radiographics. 2011; 31(4):1107–1121.
15. Yassa, MA, et al. Pattern separation in the hippocampus.
Trends Neurosci. 2011; 34(10):515–525.
16. Bonelli, SB, et al. Imaging memory in temporal lobe epilepsy:
predicting the effects of temporal lobe resection. Brain.
2010; 133(Pt 4):1186–1199.
17. Burianova, H, et al. A common functional brain network for
autobiographical, episodic, and semantic memory retrieval.
Neuroimage. 2010; 49(1):865–874.
18. Carr, VA, et al. Imaging the human medial temporal lobe
with high-resolution fMRI. Neuron. 2010; 65(3):298–308.
19. Duncan, JS. Imaging in the surgical treatment of epilepsy.
Nat Rev Neurol. 2010; 6(10):537–550.
20. Labudda, K, et al. Presurgical language fMRI activation
correlates with postsurgical verbal memory decline in left-
sided temporal lobe epilepsy. Epilepsy Res. 2010; 92(2-
3):258–261.
21. Seeley, WW, et al. Neurodegenerative diseases target large-
scale human brain networks. Neuron. 2009; 62(1):42–52.
22. Kahn, I, et al. Distinct cortical anatomy linked to subregions
of the medial temporal lobe revealed by intrinsic functional
connectivity. J Neurophysiol. 2008; 100(1):129–139.
23. Addis, DR, et al. Consequences of hippocampal damage
across the autobiographical memory network in left
temporal lobe epilepsy. Brain. 2007; 130(Pt 9):2327–2342.
24. Squire, LR, et al. The medial temporal lobe. Annu Rev
Neurosci. 2004; 27:279–306.
Social Network
Main Text
IM AGING ANATOM Y
Overview
• Distributed set of brain regions are thought to participate in

social cognition, each contributing functionality to specific
social interactions
• Mirror neuron system: Set of neurons in premotor cortex,

supplementary motor area, inferior parietal lobe, and
primary somatosensory cortex that are active both when
individual performs action and when individual perceives
others performing similar action
• Theory of mind: Inferring mental states of others likely
involves default mode network regions and posterior
superior temporal sulcus
• DMN: High overlap between proposed social brain regions
and DMN regions processing semantic knowledge and
internally directed cognition
• Social brain modules: Subnetworks responsible for discrete
social functions, such as facial processing, language,
perception of biological motion, and anticipation of others'
behavior
Posterior Superior Temporal Sulcus
• Core hub of social cognition, likely involving Wernicke area

on left (receptive language) and activated across wide range
of social tasks
Medial Prefrontal
• Judgment, valuation, and internal stimulus processing
Posterior Cingulate/Precuneus
• Processing of internal stimuli and narrative
Temporoparietal Junction
• Participates in inferring goals, intentions, and desires of

others
Anterior Insula
• Involved in control of attention, interoception, empathy,

perception of disgust, olfaction, and other functions related
to social interaction
Anterior (Mid) Cingulate
• Participates in cognition of salient stimuli, empathy, and

response inhibition
Amygdala
• Recruited during emotionally poignant social interactions

Fusiform Gyrus
• Fusiform face area processes facial recognition
Anterior Temporal Pole
• Complex polymodal association cortex involved in language,

imagery, and semantic functions
Orbitofrontal Cortex
• Involved in adaptive learning and valuation of social stimuli,

emotional regulation, and hedonic experience
Left Inferior Frontal Gyrus
• Participates in productive language (Broca area) and

planning of conversation
Intraparietal Sulcus
• Attention to external polymodal sensory stimuli
Hypothalamus/Neurohypophysis
• Releases oxytocin and arginine vasopressin (AVP), which

modulate trust and social bonding through unknown
mechanisms
Clinical Importance
• Autism: Areas of abnormal functional connectivity

specifically involve hubs of social brain
• Williams syndrome: Prosocial traits despite cognitive
impairment with increased levels of baseline oxytocin
• Down syndrome: Poor activation of amygdala in response to
threats and relative inattention to violence
Image Gallery
Print Images
SOCIAL BRAIN ANATOMY
Regions involved in social cognition are shown. Red regions
are involved in communication, mentalizing, and thinking
about the mental states of others. Blue regions are involved
in emotion, judgment, memory, and adaptive learning.
Green regions are active during empathy. Yellow regions
participate in working memory, mirroring, simulation, and
reorienting to relevant stimuli.
Group activation map shows results from 15 normal

volunteers while watching 50 minutes of Bugs Bunny
cartoons with a threshold of P < .001. Blue contrast is in
response to times when Bugs Bunny is on screen. Red
contrast is in response to times when the antagonist is on
screen. Purple areas show activation for both. Both
contrasts show similar distribution of activation, including
attentional regions along the intraparietal sulcus and in the
frontal eye fields. Strong activation is seen in bilateral area
middle temporal, extending to the posterior superior
temporal sulcus.
Selected References
1. Alcalá-López, D, et al. Computing the social brain
connectome across systems and states. Cereb Cortex. 2018;
28(7):2207–2232.
2. Richardson, H, et al, Development of the social brain from
age three to twelve years. Nat Commun 9 1 2018 1027
3. Tremblay, S, et al. Social decision-making and the brain: a
comparative perspective. Trends Cogn Sci. 2017; 21(4):265–
276.
4. Domes, G, et al. Effects of intranasal oxytocin on the neural
basis of face processing in autism spectrum disorder. Biol
Psychiatry. 2013; 74(3):164–171.
5. Bernhardt, BC, et al. The neural basis of empathy. Annu Rev
Neurosci. 2012; 35:1–23.
6. Frith, CD, et al. Mechanisms of social cognition. Annu Rev
Psychol. 2012; 63:287–313.
7. Gotts, SJ, et al. Fractionation of social brain circuits in
autism spectrum disorders. Brain. 2012; 135(Pt 9):2711–
2725.
8. Kennedy, DP, et al. The social brain in psychiatric and
neurological disorders. Trends Cogn Sci. 2012; 16(11):559–
572.
9. Lahnakoski, JM, et al. Naturalistic FMRI mapping reveals
superior temporal sulcus as the hub for the distributed
brain network for social perception. Front Hum Neurosci.
2012; 6:233.
10. Mars, RB, et al. On the relationship between the “default
mode network” and the “social brain”. Front Hum Neurosci.
2012; 6:189.
11. Beauchamp, MS. Biological motion and multisensory
integration: the role of the superior temporal sulcus. In:
Adams R, et al, eds. The Science of Social Vision. New York:
Oxford University Press; 2011:409.
12. Tsapkini, K, et al. The function of the left anterior temporal
pole: evidence from acute stroke and infarct volume. Brain.
2011; 134(Pt 10):3094–3105.
13. Ross, LA, et al. Social cognition and the anterior temporal
lobes. Neuroimage. 2010; 49(4):3452–3462.
14. Adolphs, R. The social brain: neural basis of social
knowledge. Annu Rev Psychol. 2009; 60:693–716.
15. Guastella, AJ, et al. A randomized controlled trial of
intranasal oxytocin as an adjunct to exposure therapy for
social anxiety disorder. Psychoneuroendocrinology. 2009;
34(6):917–923.
16. Van Overwalle, F. Social cognition and the brain: a meta-
analysis. Hum Brain Mapp. 2009; 30(3):829–858.
17. Blakemore, SJ. The social brain in adolescence. Nat Rev
Neurosci. 2008; 9(4):267–277.
18. Frith, CD, et al. Social cognition in humans. Curr Biol. 2007;
17(16):R724–R732.
19. Olson, IR, et al. The enigmatic temporal pole: a review of
findings on social and emotional processing. Brain. 2007;
130(Pt 7):1718–1731.
20. Gallese, V, et al. A unifying view of the basis of social
cognition. Trends Cogn Sci. 2004; 8(9):396–403.
21. Kanwisher, N, et al. The fusiform face area: a module in
human extrastriate cortex specialized for face perception. J
Neurosci. 1997; 17(11):4302–4311.
22. Baron-Cohen, S, et al. Does the autistic child have a “theory
of mind”? Cognition. 1985; 21(1):37–46.
SECT ION 4
INFRATENTORIAL BRAIN
Outline

Chapter 45: Pons
Chapter 46: Medulla
Brainstem and Cerebellum Overview
Main Text
T ERM INOLOGY
Abbreviations
• Cerebrospinal fluid (CSF)

• Cranial nerves (CN): Oculomotor nerve (CNIII), trochlear
nerve (CNIV), trigeminal nerve (CNV), abducens nerve
(CNVI), facial nerve (CNVII), vestibulocochlear nerve
(CNVIII), glossopharyngeal nerve (CNIX), vagus nerve
(CNX), accessory nerve (CNXI), hypoglossal nerve (CNXII)
Synonyms
• Classical nomenclature (simplified nomenclature)

Superior (tentorial), inferior (suboccipital), anterior
(petrosal) cerebellar surfaces
Primary (tentorial), horizontal (petrosal),
prebiventral/prepyramidal (suboccipital) cerebellar
fissures
Definitions
• Posterior fossa: Houses brainstem & cerebellum, below

tentorium cerebelli (infratentorial)
• Brainstem: Composed of midbrain (mesencephalon), pons,
& medulla oblongata
• Cerebellum: Largest part of hindbrain, integrates
coordinations & fine-tuning of movement & regulation of
muscle tone
GROSS ANATOMY
Overview
• Posterior fossa : Infratentorial contents

Protected space surrounded by calvarium, contains
– Brainstem anteriorly, cerebellum posteriorly
– Cerebral aqueduct & 4th ventricle
– CSF cisterns containing CNs, vertebrobasilar arterial
system, & veins
CSF cisterns suspend & cushion brainstem & cerebellum
• Brainstem
Anatomic divisions
– Midbrain (mesencephalon) : Upper brainstem,
connects pons & cerebellum with forebrain
– Pons : Mid portion of brainstem, relays information
from brain to cerebellum
– Medulla : Caudal (inferior) brainstem, relays
information from spinal cord to brain
Functional divisions
– Ventral part: Contains large descending white matter
tracts: Midbrain cerebral peduncles, pontine bulb,
medullary pyramids
– Dorsal part: Tegmentum, common to midbrain,
pons, & medulla; contains CN nuclei & reticular
formation
• Cerebellum
2 hemispheres & midline vermis, 3 surfaces
Connected to brainstem by 3 paired peduncles
Cortical gray matter, central white matter, & 4 paired
deep gray nuclei
• Posterior fossa boundaries

Tentorium cerebelli superiorly
Bony clivus anteriorly
Temporal bones & calvarium laterally
Foramen magnum & calvarium inferiorly
• Midbrain
Ventral: Cerebral peduncles (crus cerebri) containing
corticospinal, corticobulbar, & corticopontine tracts
Dorsal tegmentum : Ventral to cerebral aqueduct
– White matter tracts: Medial longitudinal fasciculus,
medial lemniscus, lateral lemniscus, spinothalamic
tract, central tegmental tract
– Gray matter: Substantia nigra & red nucleus
– Upper midbrain: Contains CNIII nucleus, at superior
colliculus level
– Lower midbrain: Contains CNIV nucleus, at inferior
colliculus level
Tectum (quadrigeminal plate) : Dorsal to cerebral
aqueduct
– Superior & inferior colliculi
– Periaqueductal gray matter
• Pons
Ventral: Longitudinal fibers primarily from corticospinal,
corticobulbar, & corticopontine tracts
Dorsal tegmentum: White matter tracts & CN nuclei
medial lemniscus, lateral lemniscus, trapezoid body,
spinothalamic tract, central tegmental tract
– Upper pons: Contains main nuclei of CNV
– Lower pons: Contains nuclei of CNIV, VII, & VIII
• Medulla
Ventral: Olives & pyramids
Dorsal tegmentum : White matter tracts & CN nuclei
medial lemniscus, spinothalamic tract, central
tegmental tract, spinocerebellar tract
– CN nuclei: CNIX, X, & XI (bulbar portion) in upper &
mid medulla; CNXII nuclei in mid medulla
• Cerebellum
3 surfaces: Superior (tentorial), inferior (suboccipital),
anterior (petrosal)
2 hemispheres & midline vermis
– Divided into lobes & lobules by transverse fissures
– Major fissures: Primary (tentorial), horizontal
(petrosal), prebiventral/prepyramidal (suboccipital)
cerebellar fissures
3 paired peduncles
– Superior cerebellar peduncle (brachium
conjunctivum) connects to cerebrum via midbrain
– Middle cerebellar peduncle (brachium pontis)
connects to pons
– Inferior cerebellar peduncle (restiform body)
connects to medulla
• Vertebrobasilar system
Midbrain: Perforating branches from basilar, superior
cerebellar, & posterior cerebral arteries
Pons: Superior cerebellar artery, perforating branches of
basilar artery
Medulla: Anterior spinal artery, vertebral artery
penetrating branches, posterior inferior cerebellar artery
Cerebellum: Superior cerebellar, posterior inferior
cerebellar, & anterior inferior cerebellar arteries
Image Gallery
Print Images
GRAPHICS
Sagittal midline graphic of the posterior fossa demonstrates

the anterior brainstem & posterior cerebellum, separated by
the 4th ventricle. The brainstem consists of the midbrain
(mesencephalon), pons, & medulla. The cerebellum has
superior (tentorial), inferior (suboccipital), & anterior
(petrosal) surfaces. The primary (tentorial) fissure &
horizontal (petrosal) fissures divide the vermis & cerebellar
hemispheres into lobules. The horizontal (petrosal) fissure is
the most prominent fissure on the anterior (petrosal)
surface & curves posteriorly onto the inferior (suboccipital)
surface.
Coronal graphic of the anterior brainstem & exiting cranial

nerves is shown. CNIII-CNXII nuclei are located within the
brainstem. CNIII & IV nuclei are within the midbrain, CNV-
CNVIII nuclei are within the pons, CNIX-CNXII nuclei are
within the medulla. CNIV is only dorsally exiting the CN &
wraps around the lateral midbrain in the tentorial margin.
7T AXIAL T2-SPACE MR
First of 6 axial T2-SPACE MR images at 7T from inferior to

superior shows the inferior posterior fossa at the junction of
the cervical spinal cord & medulla. Cerebellar tonsils are
seen at the foramen magnum.
Image at the level of the inferior "closed" medulla shows the
ventral (anterior) medullary pyramids & olives, which include
white matter fibers from corticospinal & corticobulbar tracts
that continue through the ventral pons & ventral midbrain.
Dorsal median sulcus continues superiorly to divide the floor
of the 4th ventricle.
Image of the mid medulla shows hypoglossal eminence,
formed by hypoglossal nerve (CNXII) nucleus as a bulge in
the 4th ventricular floor. CNXII exits the anterolateral
medulla in the preolivary sulcus while glossopharyngeal
(CNIX), vagus (CNX), & cranial roots of the accessory
(CNXI) nerves exit the lateral medulla in the postolivary
sulcus, posterior to the medullary olive.
Image more superiorly at the pontomedullary junction shows
the inferior cerebellar peduncles (restiform body) where
cochlear nuclei of the vestibulocochlear nerve (CNVIII) are
found. CNVIII is seen exiting from the cerebellopontine
angle. Abducens nerve (CNVI) exits anteriorly at the
pontomedullary junction.
Image at the mid pons shows the middle cerebellar
peduncles (brachium pontis) & major cerebellar structures.
The facial colliculus, formed by axons of the facial nerve
(CNVII) looping around the abducens nucleus (CNVI),
creates a bulge in the floor of the 4th ventricle. The
trigeminal nerve (CNV) is seen as it courses toward the
Meckel cave (visible in the upper image). Dentate nucleus is
the only cerebellar nucleus that is seen on imaging.
Image at the superior pons shows superior cerebellar
peduncles (brachium conjunctivum). Corticospinal tracts are
present in the ventral pons.
7T AXIAL T2 MR
First of 3 T2 turbo spin-echo images at 7T shows the
junction of the pons & midbrain. Major white matter tracts,
including corticospinal tracts & medial longitudinal fasciculus,
can sometimes be detected at 7T MR.
Image at the inferior midbrain shows interpeduncular fossa
where the oculomotor nerve (CNIII) exits. Trochlear nucleus
(CNIV) is present in paramedian gray matter, just dorsal to
the medial longitudinal fasciculus, approximate location
shown. CNIV decussates in the superior medullary velum,
exits dorsally, & wraps around the midbrain in the ambient
cistern.
Image of superior midbrain shows cerebral peduncles
where major white matter tracts, including corticospinal
tracts, travel. Major pigmented gray nuclei, substantia nigra,
& red nucleus are seen. Oculomotor nerve (CNIII) nucleus is
present at the level of the superior colliculus, approximate
location shown.
7T AXIAL T1 MP-RAGE
First of 6 axial T1 MP-RAGE images at 7T from inferior to
superior through the posterior fossa at the level of the
medulla is shown. Dorsal medulla (tegmentum) contains CN
nuclei & white matter tracts, which can be identified by the
typical location but are not directly visualized.
Image at the level of the superior medulla/pontomedullary
junction shows inferior cerebellar peduncles (restiform
body) where cochlear nuclei arise. Cerebellar flocculus is a
common pseudolesion.
Image at the level of the lower pons shows facial nerve
(CNVII) & the vestibulocochlear nerve (CNVIII) coursing
toward the interior auditory canal. The nodulus of the vermis
may protrude into the 4th ventricle & cause a pseudolesion.
Middle cerebellar peduncle (brachium pontis) is a major
cerebellar peduncle & contains fibers from pontine nuclei.
Image more superiorly through the mid pons shows middle
cerebellar peduncles & trigeminal nerve (CNV). Th facial
colliculus represents axons of the facial nerve (CNVII)
wrapping around the nucleus of abducens nerve (CNVI).
Image at the superior pons shows the superior cerebellar
peduncle (brachium conjunctivum). The approximate location
of the medial longitudinal fasciculus is shown, just lateral to
the midline, which is important in extraocular muscle
movement & head location. In this specific participant, an
arachnoid cyst is visible. The majority of arachnoid cysts
form outside the temporal lobe of the brain in an area of the
skull known as the middle cranial fossa.
Image through the midbrain at the superior colliculus shows
the approximate location of oculomotor nerve (CNIII)
nucleus. Cerebral peduncles (crus cerebri) contain
descending white matter tracts from cerebral hemispheres,
including corticospinal, corticobulbar, & corticopontine
tracts. Periaqueductal gray surrounds the cerebral
aqueduct.
7T CORONAL T2 MR
First of 6 coronal T2 turbo spin-echo MR images at 7T
through the posterior fossa from posterior to anterior shows
a prominent horizontal (petrosal) fissure of the cerebellum,
which extends from the middle cerebellar peduncle onto the
inferior (suboccipital) surface of the cerebellum.
This image shows continuation of the midbrain, pons, &
medulla. Cerebral peduncles contain corticospinal & other
white matter tracts, which are continuous with anterior
(ventral) pons white matter tracts & continue to extend to
medullary pyramids in the ventral medulla.
Image through the brainstem at the level of the internal
auditory canals is shown. The trigeminal nerve (CNV) is
seen arising from the lateral pons. The facial (CNVII) &
vestibulocochlear (CNVIII) nerves are seen coursing in the
cerebellopontine angle to the internal auditory canal. The
vertebrobasilar system is seen, which supplies vast the
majority of the brainstem & cerebellum.
Image more anteriorly shows the anterior aspect of the
pons, pons belly or bulb, which contains multiple transverse
pontine fibers & descending tracts. The vertebral arteries
form the basilar artery in the region of the pontomedullary
junction. The posterior inferior cerebellar artery arises from
the vertebral artery & has a reciprocal relationship with the
anterior inferior cerebellar artery, which arises from the
basilar artery.
This image shows oculomotor nerve (CNIII) coursing
between the posterior cerebral artery above & superior
cerebellar artery below. The basilar artery is seen coursing
along the anterior surface of pons, giving rise to the
superior cerebellar & posterior cerebral arteries.
Image through the anterior pons shows trigeminal nerve
(CNV) entering the porus trigeminus of the Meckel cave.
The pons is supplied by perforating branches from the
basilar artery & superior cerebellar artery branches. These
are called pontine arteries and are usually visible at 7T.
7T SAGITTAL T2-SPACE MR
First of 3 sagittal T2-SPACE MR images at 7T from medial
to lateral shows midline posterior fossa structures situated
below the tentorium cerebelli. The brainstem is anterior &
separated from the cerebellum by the cerebral aqueduct &
4th ventricle. The brainstem consists of the midbrain
(mesencephalon), pons, & medulla. Major fissures of the
cerebellum separate the cerebellum & vermis into lobules.
Image just lateral of the midline shows continuation of the
primary (tentorial) & horizontal (petrosal) fissures dividing
the cerebellar hemisphere into lobules. The superior &
inferior medullary velum makes up the roof of the 4th
ventricle. The floor of the 4th ventricle is formed by the
dorsal brainstem. The superior & inferior colliculi of the
tectum are seen.
Image more lateral shows white matter core of the
cerebellum, arbor vitae (tree of life). The largest gray
nucleus of the cerebellum, dentate nucleus is visible.
Midbrain
Main Text
T ERM INOLOGY
Abbreviations
• Cerebrospinal fluid (CSF)

• Cranial nerves (CN): Oculomotor nerve (CNIII), trochlear
nerve (CNIV)
Synonyms
• Midbrain, mesencephalon
Definitions
• Midbrain: Portion of brainstem that connects pons and

cerebellum with forebrain
GROSS ANATOMY
Overview
• Butterfly-shaped upper brainstem that passes through

hiatus in tentorium cerebelli
• Composed of gray matter formations, CN nuclei (CNIII-
CNIV), and white matter tracts
• 3 main parts
Cerebral peduncles : White matter tracts
– Continuous with pontine bulb and medullary
pyramids
Tegmentum : CN nuclei, gray matter nuclei, white
matter tracts
– Continuous with pontine tegmentum
– Ventral to cerebral aqueduct
Tectum (quadrigeminal plate) : Superior and inferior
colliculi
– Dorsal to cerebral aqueduct
• Midbrain connections
Rostral (superior): Cerebral hemispheres, basal ganglia,
and thalami
Dorsal (posterior): Cerebellum
Caudal (inferior): Pons
• Cerebral aqueduct passes through dorsal midbrain between
tectum posteriorly and tegmentum anteriorly, connecting
3rd and 4th ventricles
• Adjacent CSF cisterns
Interpeduncular: Anterior, contains CNIII
Ambient (perimesencephalic): Lateral, contains CNIV
Quadrigeminal plate: Posterior, contains CNIV
• Blood supply by vertebrobasilar circulation
Small perforating branches from basilar, superior
cerebellar, and posterior cerebral arteries
Cerebral Peduncles (Crus Cerebri)
• Corticospinal, corticobulbar, and corticopontine fibers

• Cerebral peduncles separated in midline by interpeduncular
fossa
Mesencephalic Tegmentum
• Directly continuous with pontine tegmentum, contains same
tracts
• Multiple white matter tracts (not resolved on conventional
imaging)
Medial longitudinal fasciculus : Oculomotor-vestibular
Medial lemniscus : Somatosensory
Lateral lemniscus : Auditory
Spinothalamic tract : Somatosensory
Central tegmental tract : Motor
• Gray matter formations
Substantia nigra : Pigmented nucleus, extends through
midbrain from pons to subthalamic region, important in
movement
– Pars compacta: Contains dopaminergic cells
(atrophied in Parkinson disease)
– Pars reticularis: Contains GABAergic cells
Red nucleus : Relay and control station for cerebellar,
globus pallidus, and corticomotor impulses
– Important for muscle tone, posture, locomotion
Periaqueductal gray : Surrounds cerebral aqueduct
– Important in modulation of pain and defensive
behavior
• CN nuclei
CNIII nuclei at superior colliculus level
– Paramedian, anterior to cerebral aqueduct
– Motor nuclei consists of 5 individual motor
subnuclei that supply individual extraocular muscles
– Edinger-Westphal parasympathetic nuclei: Dorsal to
CNIII nucleus in periaqueductal gray
– CNIII fibers course anteriorly through midbrain to
exit at interpeduncular fossa
CNIV nuclei at inferior colliculus level
– Paramedian, anterior to cerebral aqueduct
– Dorsal to medial longitudinal fasciculus
– CNIV fibers course posteriorly around cerebral
aqueduct, decussate in superior medullary velum
– CNIV exits dorsal midbrain just inferior to inferior
colliculus
• Reticular formation : Expands from medulla to rostral
midbrain
Occupies central tegmentum
Afferent and efferent connections
Important in consciousness, motor function, respiration,
and cardiovascular control
Tectum (Quadrigeminal Plate)
• Superior colliculi : Visual pathway

• Inferior colliculi : Auditory pathway
IMAGING ANATOMY
Overview
• CNIII and CNIV seen as they exit midbrain

CNIII at level of superior colliculus, seen in
interpeduncular fossa
CNIV at level of inferior colliculus, seen dorsally and in
ambient cistern as wraps around midbrain
• Cerebral aqueduct: Signal varies due to flow artifact
• CN nuclei and white matter tracts can be identified by
typical location but are not resolved on imaging
• Substantia nigra and red nucleus well seen

• MR for cranial neuropathy or acute ischemia

• CT may be helpful in acute setting
• CTA and MRA for vertebrobasilar circulation
Image Gallery
Print Images
GRAPHICS
Axial graphic through level of superior colliculus shows

oculomotor nucleus (CNIII) just anterior to cerebral
aqueduct. CNIII exits into interpeduncular fossa. Cerebral
peduncles are anterior & contain corticospinal & other white
matter tracts. Tegmentum is anterior & tectum is posterior
to cerebral aqueduct. Substantia nigra consists of 2 layers
of cells: Pars compacta posteriorly & pars reticulata
anteriorly & plays a vital role in Parkinson disease.
Axial graphic of midbrain at level of inferior colliculi shows

trochlear nucleus (CNIV) & nerve fibers as they decussate
in superior medullary velum, which forms roof of 4th
ventricle. Each superior oblique muscle is innervated by
contralateral trochlear nucleus. CNIV exits dorsally, just
inferior to inferior colliculus & is the only cranial nerve to exit
dorsal brainstem.
7T AXIAL T1 MR
First of 6 axial T1 MR images of midbrain from inferior to

superior shows junction of pons with inferior midbrain. The
brainstem tegmentum is dorsal & is common to all 3 parts
of the brainstem: Medulla, pons, & midbrain. At pons level,
tegmentum is covered by cerebellum, while at midbrain
level, tectal plate (superior & inferior colliculi) covers
tegmentum.
Image through inferior midbrain shows location of trochlear
nucleus (CNIV), in paramedian midbrain anterior to cerebral
peduncle at level of inferior colliculus. Although not seen,
medial longitudinal fasciculus is just ventral (anterior) to
CNIV nucleus.
Image through inferior midbrain & inferior colliculus shows
superior medullary velum, which contains decussation of
CNIV. CNIV exits dorsally & wraps around midbrain in
ambient cistern.
Image through superior midbrain at level of superior
colliculus shows approximate location of oculomotor nerve
(CNIII) nucleus along anterolateral periaqueductal gray.
CNIII exits midbrain in interpeduncular fossa. Pigmented
nuclei, substantia nigra, & red nucleus are seen at this level,
although are better seen on T2.
Image through superior midbrain shows cerebral peduncles
as they descend from cerebral hemispheres. Cerebral
peduncles (crus cerebri) contain descending white matter
tracts from cerebral hemispheres, including corticospinal,
corticobulbar, & corticopontine tracts. Periaqueductal gray
surrounds cerebral aqueduct & is important in modulation of
pain & defensive behavior.
Image through junction of midbrain with inferior basal
ganglia is shown. White matter tracts extend from midbrain
to basal ganglia & thalamus.
7T AXIAL T2 MR
First of 6 axial T2 MR images (high-resolution T2-SPACE at
7T using 0.4-mm isotropic resolution using parallel transit
RF coil) from inferior to superior through midbrain shows
junction of pons & midbrain. White matter tracts including
corticospinal tracts & medial longitudinal fasciculus continue
into midbrain in approximately same location as they are
seen in pons.
Posterior cerebral artery is noted just anterior to CNIII.
CNIII passes between posterior cerebral artery & superior
cerebellar artery. A posterior communicating artery
aneurysm may result in a CNIII palsy. Oculomotor nerves
(CNIII) exit midbrain at interpeduncular fossa.
Image at inferior midbrain shows trochlear nerve (CNIV) as
it wraps around midbrain in ambient cistern. It is only cranial
nerve to exit dorsally from brainstem. Using high-resolution
imaging at 7T, perivascular spaces in midbrain can be
visualized, mainly due to the high fluid-to-tissue contrast.
More superior image shows midbrain at level of superior 4th
ventricle. Oculomotor nerve (CNIII) is seen in
interpeduncular fossa as it heads toward cavernous sinus.
Substantia nigra visibility is substantially improved at 7T
MR, providing a clear delineation with cerebral peduncle.
Image more superiorly shows midbrain at level of cerebral
aqueduct. Trochlear nucleus CNIV is located in paramedial
gray matter, just dorsal to medial longitudinal fasciculus,
approximate location shown. Red nucleus & substantia nigra
are delineated from cerebral peduncle & the rest of the
midbrain.
Image more superiorly in a different patient shows superior
midbrain at level of superior colliculi. The pigmented nuclei,
substantia nigra, & red nucleus are well seen. Substantia
nigra contains 2 parts, pars compacta & pars reticularis.
Pars compacta becomes atrophied in Parkinson disease
where there is a loss of dopaminergic cells. Oculomotor
nucleus (CNIII) is present at this level, approximate location
shown.
Pons
Main Text
T ERM INOLOGY
Abbreviations
• Cerebellopontine angle (CPA)

• Cranial nerves (CN): Trigeminal nerve (CNV), abducens
nerve (CNVI), facial nerve (CNVII), vestibulocochlear nerve
(CNVIII)
Definitions
• Pons: Portion of brainstem that relays information from

brain to cerebellum
GROSS ANATOMY
Overview
• Bulbous midportion of brainstem located between midbrain

(superiorly) & medulla oblongata (inferiorly)
• Composed of gray matter formations, CN nuclei (CNV-
CNVIII), & white matter tracts
• 2 main parts
Ventral (anterior) pons: White matter tracts
– Continuous with cerebral peduncles superiorly &
medullary pyramids inferiorly
Dorsal tegmentum: CN nuclei, gray matter nuclei, white
matter tracts
– Continuation of midbrain tegmentum superiorly &
medullary tegmentum inferiorly
• Dorsal surface of pons forms rostral 1/2 of rhomboid fossa of
4th ventricle
Prepontine cistern: Anterior to pons; contains CNV &
CNVI
CPA cistern: Lateral to pons; contains CNVII & CNVIII
• Blood supply by vertebrobasilar circulation
Medial branches of superior cerebellar arteries
Perforating branches of basilar artery, thalamoperforator
arteries
Ventral (Anterior) Pons
• Contains longitudinal fibers primarily from corticospinal,

corticobulbar, & corticopontine tracts
• Multiple transverse pontine fibers make up bulk
• May be referred to as pontine bulb or belly
Dorsal Tegmentum
• Continuation of medulla except medullary pyramids

• Multiple white matter tracts of tegmentum (not resolved on
conventional imaging)
Medial lemniscus: Somatosensory
Medial longitudinal fasciculus: Oculomotor-vestibular
Lateral lemniscus: Auditory
Trapezoid body: Auditory
Spinothalamic tract: Somatosensory
Central tegmental tract: Motor
• Cranial nerve nuclei
CNV nuclei located throughout brainstem & upper cord
– Bulk of motor, main sensory, & mesencephalic nuclei
located in pons
CNVI nucleus
– Nucleus located in pontine tegmentum near midline,
anterior to 4th ventricle
– Axons of facial nerve (CNVII) loop around abducens
nucleus creating bulge in floor of 4th ventricle, facial
colliculus
CNVII nucleus
– CNVII has 3 main nuclei within pons: Motor,
superior salivatory, solitary tract
– Located in ventrolateral aspect of tegmentum of
lower pons
CNVIII nuclei
– CNVIII has cochlear & vestibular nuclei
– Vestibular nuclei beneath lateral recess along floor of
4th ventricle (rhomboid fossa)
– Dorsal & ventral cochlear nuclei on lateral surface of
inferior cerebellar peduncle (restiform body)
IMAGING ANATOMY
Overview
• CN root entry & exit zones visualized

CNV root entry zone at midlateral pons
CNVI exit brainstem anteriorly at pontomedullary
junction
CNVII exit lateral brainstem at root exit zone in
pontomedullary junction
CNVIII enters brainstem, posterior to CNVII at
pontomedullary junction
• CN nuclei not resolved on conventional imaging
• Specific white matter tracts can be identified by typical
location but are not resolved on imaging
• CPA: Junction between pons & cerebellum

• CT may be useful for acute setting

Pontine hemorrhage, ischemia
• MR for cranial neuropathy
• Diffusion imaging for acute ischemia
• CTA & MRA for vertebrobasilar circulation
Clinical Issues
• White matter lesions affecting middle cerebellar peduncle

(brachium pontis) or location of medial longitudinal
fasciculus, think demyelination
• Hypertensive hemorrhages & lacunar infarcts are common
pontine lesions
• Acute pontine ischemia often not seen on routine CT or MR
Use diffusion weighted imaging (DWI) sequence when
acute ischemia suspected
• Osmotic demyelination (central pontine myelinolysis) is
characterized by central T1 hypointensity & T2
hyperintensity in ventral pons
• Cerebellopontine angle lesions are common
Enhancing mass: Vestibulocochlear schwannoma (most
common) or meningioma
Nonenhancing: Epidermoid or arachnoid cyst
Don't forget posterior circulation aneurysm for fusiform
or unusual masses
Image Gallery
Print Images
GRAPHICS
Axial graphic of the pons at the level of the trigeminal nerve

shows the main trigeminal nuclei: The main sensory nucleus,
motor nucleus, & mesencephalic nucleus. Root entry zone
of CNV is seen as a preganglionic segment of CNV.
Corticospinal tracts are seen as transversely cut fiber
bundles, which continue as pyramidal tract into medulla.
Medial longitudinal fasciculus (MLF) is noted just anterior to
the 4th ventricle & is important in extraocular muscle
movement. A lesion involving the MLF may result in
internuclear ophthalmoplegia, which is often associated with
multiple sclerosis.
Axial graphic of the pons at the level of CNVI & CNVII is

shown. Axons of CNVII loop around CNVI nucleus creating
a bulge in the 4th ventricle, facial colliculus. CNVII has 3
main nuclei: Motor, superior salivatory, & solitarius tract
nuclei. The middle cerebellar peduncle is a common location
for multiple sclerosis plaques.
7T AXIAL T1 MR
First of 6 axial T1 MP-RAGE MR images at 7T of the pons

from inferior to superior shows the pontomedullary junction
& the inferior aspect of the inferior cerebellar peduncle
(restiform body). Cochlear nerve nuclei are found on the
lateral surface of the inferior cerebellar peduncle. The
posterior inferior cerebellar artery, arising from the right
vertebral artery, is also noticeable. The glossopharyngeal
nerve (CNIX) exits laterally between the olive & the inferior
cerebellar peduncle.
Image through the inferior pons shows the cisternal

segment of CNVI as it ascends anterosuperiorly in
prepontine cistern. The basilar artery is seen anteriorly
along the belly of the pons as it sits in a shallow median
sulcus. CNVII & VIII exit laterally in the pontomedullary
junction to enter the cerebellopontine angle (CPA) cistern.
Image through the pons at the level of the facial colliculus,
which is formed by axons of CNVII as they wrap around the
nucleus of CNVI just anterior to the 4th ventricle, is shown.
A lesion in this location would result in both CNVI & CNVII
palsies.
A more superior image through the pons at the level of the
CNV root entry zone, where CNV exits the lateral pons, is
shown. From here, CNV courses anteriorly through the
prepontine cistern, passes over the petrous ridge, & enters
the middle cranial fossa passing through the porus
trigeminus to enter the Meckel cave. The Meckel cave is an
arachnoid-lined, dural diverticulum filled with CSF & houses
the trigeminal ganglion.
Image through the superior pons shows the approximate
location of the corticospinal tracts, which continue as
pyramidal tracts into the medulla. The anterior aspect of the
pons, which contains corticospinal tracts, will become
atrophied in cortical strokes that affect the motor cortex
related to wallerian degeneration.
location of the MLF, just lateral to the midline. The MLF is
important in extraocular muscle movement. The superior
cerebellar arteries arise from the basilar artery before this
divides into the posterior cerebral arteries.
7T AXIAL T2 MR
First of 6 axial T2-SPACE MR images at 7T of the pons
from inferior to superior shows the pontomedullary junction
& the inferior aspect of the inferior cerebellar peduncle
(restiform body). CNVI exits the brainstem anteriorly at the
pontomedullary junction just above the medullary pyramid.
CNVII & CNVIII exit laterally at the pontomedullary junction.
The inferior cerebellar peduncle (restiform body) lateral
surface is where the dorsal & ventral cochlear nuclei are
found.
Image through the inferior pons shows the cisternal
segment of CNVI as it ascends in the prepontine cistern.
The basilar artery is seen anteriorly. It gives rise to the
thalamoperforator arteries, which supply the majority of the
pons & the anterior inferior cerebellar arteries, which loop in
the region of the internal auditory canals.
Image through the mid pons shows the middle cerebellar
peduncle (brachium pontis), a common location for multiple
sclerosis plaques and other demyelinating processes.
A more superior image through the pons at the level of the
CNV root entry zone, where CNV exits the lateral pons, is
shown. From here, CNV courses through the prepontine
cistern, enters the middle cranial fossa, & passes through
the opening in the dura to enter the Meckel cave, which
houses the trigeminal ganglion. The 3 branches of the
trigeminal nerve (ophthalmic, maxillary, & mandibular) are
visible at 7T.
Image through the superior pons shows the superior
cerebellar peduncles. The superior medullary velum, a thin
sheet of tissue that covers the dorsal 4th ventricle, attaches
laterally to the superior cerebellar peduncles. The lingula of
the cerebellar vermis overlies the superior medullary velum.
location of the corticospinal tracts & the MLF. These
specific fibers cannot be resolved on conventional imaging,
but knowledge of their location is useful when evaluating
patients with weakness or cranial neuropathies. At this
level, the basilar artery bifurcates to form the 2 posterior
cerebral arteries.
7T CORONAL T2 MR
First of 6 coronal T2 MR images at 7T of the pons from
posterior to anterior shows the dorsal pons & the middle
cerebellar peduncles, the largest of the cerebellar
peduncles. The superior & inferior cerebellar peduncles are
small. The dorsal surface of the pons is hidden by the
cerebellum, which covers the posterior aspect of the 4th
ventricle (rhomboid fossa).
This image shows the pontomedullary junction at the inferior
border of the pons where the pons & medulla meet. The
cerebral peduncles, which contain corticospinal tracts, are
continuous with the anterior pons where the corticospinal
tracts continue inferiorly to the medullary pyramids.
A more anterior image shows the preganglionic segment of
CNV arising from the lateral pons. CNVII & CNVIII exit the
brainstem laterally at the pontomedullary junction & traverse
the CPA cistern before entering the internal auditory canal.
A more anterior image shows the anterior aspect of the
pons, which contains multiple transverse pontine fibers &
descending corticospinal, corticobulbar, & corticopontine
tracts. The vertebral arteries unite to form the basilar artery
in the region of the pontomedullary junction. Ectasia &
tortuosity of the vertebrobasilar system (dolichoectasia) are
often seen in elderly adults, particularly those with
atherosclerotic disease.
A more anterior image shows the preganglionic segment of
CNV, the largest of the cranial nerves, & the basilar artery.
The basilar tip is the most cephalad aspect of basilar artery
& a location for posterior circulation aneurysms.
This image shows the most anterior aspect of the pons with
the pontine perforating arteries coursing along the surface.
The pons is a common location for lacunar infarcts related
to these small perforator arteries that supply it.
Medulla
Main Text
T ERM INOLOGY
Abbreviations
• Cranial nerves (CN)

Trigeminal nerve (CNV)
Vestibulocochlear nerve (CNVIII)
Glossopharyngeal nerve (CNIX)
Vagus nerve (CNX)
Accessory nerve (CNXI)
Hypoglossal nerve (CNXII)
Definitions
• Medulla: Caudal brainstem, transition from spinal cord to

brain
GROSS ANATOMY
Overview
• Caudal part of brainstem composed of gray matter

formations, CN nuclei (CNIX-CNXII), and white matter
tracts
Located between pons (superiorly) and spinal cord
4th ventricle and cerebellum dorsal to medulla
Caudal border: 1st cervical nerves
• Medulla subdivided into 2 main parts
Ventral (anterior) medulla: Olive and pyramidal tract
Tegmentum (dorsal): CN nuclei and white matter tracts
• Medulla may also be divided into rostral (superior) defined
by 4th ventricle (open) and caudal (inferior) defined by
central canal (closed portion)
• Medulla external features
Pyramid
– Paired structure on anterior surface, separated in
midline by ventral median fissure
– Contains ipsilateral corticospinal tracts prior to
decussation more inferiorly
Olive
– Medullary olives are lateral to pyramids, separated
by ventrolateral sulcus (preolivary sulcus)
– Formed by underlying inferior olivary complex of
nuclei
– Posterolateral sulcus (postolivary sulcus) is lateral to
olives
Inferior cerebellar peduncle (restiform body)
– Arise from superior aspect of dorsal medulla;
peduncles diverge and incline to enter cerebellar
hemispheres
– Nuclei of CNVIII located along dorsal surface
Gracile and cuneate tubercles
– Form lower aspect of dorsal medulla
– Produced by paired nuclei gracilis (medial) and
cuneatus (lateral)
– Dorsal median sulcus separates gracile tubercles
• 4th ventricle
Dorsal median sulcus divides ventricular floor
longitudinally
Terminates in caudal medulla
Roof formed by superior and inferior medullary velum
• Blood supply from vertebrobasilar circulation
Distal vertebral arteries
Posterior inferior cerebellar arteries
Anterior spinal artery
Ventral (Anterior) Medulla
• Medullary pyramids
Corticospinal tracts (pyramidal tracts) make up bulk
• Medullary olives
Consists of inferior olivary nucleus, dorsal and medial
accessory olivary nuclei, and superior olivary nucleus
Inferior olivary nucleus is largest and forms bulge on
surface of medulla, "medullary olive"
Dorsal Tegmentum
• Multiple white matter tracts of tegmentum (not resolved on

conventional imaging)
Medial longitudinal fasciculus: Oculomotor-vestibular
Medial lemniscus: Auditory
Spinothalamic tract: Somatosensory
Central tegmental tract: Motor
Spinocerebellar tract: Somatosensory
• Cranial nerve nuclei
CNIX nuclei in upper and mid medulla: Nucleus
ambiguus, solitary tract nucleus, inferior salivatory
nucleus
– Sensory fibers terminate in spinal nucleus CNV
– CNIX exits medulla in postolivary sulcus above CNX
CNX nuclei in upper and mid medulla: Nucleus
ambiguus, solitary tract nucleus, dorsal vagal nucleus
– Sensory fibers terminate in spinal nucleus CNV
– CNX exits medulla in postolivary sulcus between
CNIX and CNXI
CNXI bulbar nuclei in lower nucleus ambiguus in upper
and mid medulla
– CNXI exits medulla in postolivary sulcus below CNX
CNXII nuclei in mid medulla, dorsally results in
hypoglossal eminence or trigone (bulge in 4th ventricle)
– CNXII exits anterior medulla in preolivary sulcus
• Reticular formation
Occupies central tegmentum, afferent and efferent
connections
Important in consciousness, motor function, respiration,
and cardiovascular control
IMAGING ANATOMY
Overview
• Medullary olives and pyramids well seen on imaging

• CNIX-CNXII seen as they exit medulla
CNIX-CNXI exit medulla in postolivary sulcus
CNXII exits anterior medulla in preolivary sulcus
• CN nuclei and white matter tracts can be identified by
typical location but are not resolved on imaging

• MR for cranial neuropathy or acute ischemia

• CTA and MRA for vertebrobasilar circulation
Image Gallery
Print Images
GRAPHICS
Axial graphic of the superior medulla at the level of the

pontomedullary junction shows vestibulocochlear CNVIII
nuclei. Both cochlear nuclei and 2 of 4 vestibular nuclei are
seen. Each medullary pyramid contains descending
corticospinal tracts from the ipsilateral cerebral cortex,
which have traversed the internal capsule, midbrain, and
pons. CNIX-CNXI exit the postolivary sulcus and CNXII exits
at the preolivary sulcus.
Axial graphic shows the mid medulla at the level of the
CNXII nucleus and CNX nuclei. The CNXII nucleus forms a
bulge on the floor of the 4th ventricle, hypoglossal
eminence. Fibers of CNXII cross the medulla to exit
between the pyramid and olive in the preolivary sulcus. CNX
nuclei are in the upper and middle medulla and include the
nucleus ambiguus, solitary tract nucleus, and dorsal vagal
nucleus. CNX exits the lateral medulla in the postolivary
sulcus inferior to CNIX and superior to the bulbar portion of
CNXI.
3T AXIAL T2 MR
First of 6 axial T2 MR images through the medulla from
inferior to superior shows hypoglossal nerve CNXII exiting
the medulla at the preolivary sulcus. The spinal root of
accessory nerve CNXI is seen laterally as it ascends
through the foramen magnum to unite with the cranial roots
of CNXI before exiting via the jugular foramen. The dorsal
median sulcus continues superiorly to divide the floor of the
4th ventricle longitudinally.
Image at the level of the jugular foramen shows medullary
olives and pyramids.
Axial T2 MR shows hypoglossal eminence (trigone) formed
by the CNXII nucleus as a bulge in the 4th ventricular floor.
Glossopharyngeal CNIX, vagus CNX, and cranial roots of
accessory CNXI nerves exit the lateral medulla in the
postolivary sulcus, posterior to the olive. These nerves exit
the skull base via the jugular foramen. Thin-section, high-
resolution imaging allows identification of CNIX-CNXI.
Image more superiorly shows the medullary olives
bilaterally. Olives become atrophied in the degenerative
disease multisystem atrophy-cerebellar (MSA-C),
olivopontocerebellar atrophy. Wallenberg syndrome is a
neurological condition caused by ischemia of the lateral
medulla related to vertebral or posterior inferior cerebellar
artery disease.
Image more superiorly at the level of the pontomedullary
junction is shown. Inferior cerebellar peduncle (restiform
body) is where the cochlear nuclei of the vestibulocochlear
nerve, CNVIII, are found. The abducens nerve, CNVI, exits
anteriorly at the pontomedullary junction, just above the
medullary pyramid. It is important to remember that the
anterior inferior cerebellar artery is seen about the
brainstem in order to not mistake it for a cranial nerve.
Image at the inferior pons junction with the upper medulla is
shown. The facial nerve, CNVII, and vestibulocochlear
nerve, CNVIII, exit laterally at the pontomedullary junction.
Cerebellum
Main Text
T ERM INOLOGY
Synonyms
• Classic nomenclature (simplified nomenclature): Superior

(tentorial), inferior (suboccipital), anterior (petrosal)
cerebellar surfaces
• Primary (tentorial), horizontal (petrosal),
prebiventral/prepyramidal (suboccipital) cerebellar fissures
Definitions
• Cerebellum: Integrative organ for coordination & fine-tuning

of movement & regulation of muscle tone
GROSS ANATOMY
Overview
• Bilobed posterior fossa structure located posterior to

brainstem & 4th ventricle
2 hemispheres & midline vermis
3 surfaces
Divided into lobes & lobules by transverse fissures
Connected to brainstem by 3 paired peduncles
Cortical gray matter, central white matter, & 4 paired
deep gray nuclei
• Surfaces
Superior (tentorial) surface
– Faces & conforms to inferior surface of tentorium
– Transition between vermis & hemispheres is smooth
– Primary (tentorial) fissure divides superior (tentorial)
surface into anterior & posterior parts
Inferior (suboccipital) surface
– Located below, between lateral & sigmoid sinuses
– Vermis is contained within deep vertical depression,
posterior cerebellar incisura, which separates
cerebellar hemispheres
– Prebiventral/prepyramidal (suboccipital) fissure
divides inferior (suboccipital) surface into superior &
inferior parts
– Tonsil is part of hemisphere, located on inferomedial
part of inferior (suboccipital) surface
Anterior (petrosal) surface
– Faces posterior surface of petrous bone, brainstem,
& 4th ventricle
– Vermis lies dorsal to 4th ventricle
– Horizontal (petrosal) fissure divides anterior
(petrosal) surface into superior & inferior parts
– Horizontal (petrosal) fissure continues
posterolaterally onto inferior (suboccipital) surface
• Peduncles : 3 paired peduncles attach cerebellum to
brainstem
Superior cerebellar peduncle (brachium conjunctivum)
– Connects to cerebrum via midbrain
– Contains efferent fiber systems extending to red
nucleus & thalamus
Middle cerebellar peduncle (brachium pontis)
– Connects to pons
– Contains fiber mass originating from pontine nuclei
& represents continuation of corticopontine tracts
Inferior cerebellar peduncle (restiform body)
– Connects to medulla
– Contains spinocerebellar tracts & connections to
vestibular nuclei
Cerebellopontine angle cistern: Lateral to pons
Cisterna magna: Inferior to cerebellum
Quadrigeminal plate cistern: Posterior to midbrain, above
cerebellum
Superior cerebellar cistern: Above cerebellum, below
tentorium
• Blood supply from vertebrobasilar circulation
Superior cerebellar artery, anterior inferior cerebellar
artery, & posterior inferior cerebellar artery
Cerebellar Lobes & Lobules
• Vermis : Superior & inferior, separated by horizontal

(petrosal) fissure
Superior vermis: Lingula (anterior), central lobule,
culmen, declive, folium (posterior) lobules
Inferior vermis: Tuber (posterior), pyramid, uvula,
nodule (anterior) lobules
• Lobules of vermis are associated with pair of hemispheric
lobules
Lingula: Wing of lingula
Central lobule: Wing of central lobule
Culmen: Quadrangular lobule
– Primary (tentorial) fissure
Declive: Simple lobule
Folium: Superior semilunar lobule
– Horizontal (petrosal) fissure
Tuber: Inferior semilunar lobule
– Prebiventral/prepyramidal (suboccipital) fissure
Pyramid: Biventral lobule
Uvula: Tonsils
Nodule: Flocculus
Cerebellar Nuclei
• Located deep in cerebellar white matter

• Nuclei project fibers to coordinate goal-directed movement
• Fastigial nucleus: Medial group (vermis)
Fibers from vermis cortex, vestibular nuclei, & other
medulla nuclei
• Globose (posterior) nucleus: Intermediate group
Fibers from vermis cortex, sends fibers to medulla nuclei
• Emboliform (anterior) nucleus: Intermediate group
Fibers from cerebellar cortex between vermis &
hemispheres, sends fibers to thalamus
• Dentate nucleus: Lateral group
Fibers from hemispheric cortex, sends fibers to red
nucleus & thalamus
Largest nucleus, shaped as heavily folded band with
medial opening (hilum)
Image Gallery
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GRAPHICS
Graphic of anterior (petrosal) surface of cerebellum shows
cut surfaces of cerebellar peduncles. Middle cerebellar
peduncle is largest & contains corticopontine tracts from
pons. Superior cerebellar peduncle contains fibers from red
nucleus & thalamus. Inferior cerebellar peduncle contains
spinocerebellar tracts & connections to vestibular nuclei.
Cerebellum is divided into 2 large lateral hemispheres united
by a midline vermis.
Sagittal graphic of midline cerebellum shows parts of
cerebellar vermis: Lingula (purple), central lobule (green),
culmen (orange), declive & folium (petrol blue), tuber (gray),
pyramid (red), uvula (cyan), & nodulus (magenta). Primary
(tentorial) fissure separates culmen from declive (simple).
Horizontal (petrosal) fissure separates folium from tuber,
dividing vermis into superior & inferior parts.
Prebiventral/prepyramidal (suboccipital) fissure separates
tuber from pyramid.
7T AXIAL T1 MR
First of 6 axial T1 MP-RAGE images at 7T through
cerebellum from inferior to superior shows junction of
medulla with cervical spinal cord. Cerebellar tonsils are
most inferior extension of cerebellum & may herniate
inferiorly in patients with cerebellar edema or mass,
resulting in descending tonsillar herniation.
Image shows inferior cerebellar hemispheres, which are
supplied primarily by posterior inferior cerebellar artery
(PICA). Anterior inferior cerebellar artery (AICA) supplies
anterolateral aspect of cerebellar hemispheres. Ischemia in
a PICA distribution is most common cerebellar stroke.
Image more superiorly shows inferior cerebellar peduncle
(restiform body), which ascends from lower medulla to
cerebellum & contains spinocerebellar tracts & connections
to vestibular nuclei. It is also location of cochlear nerve
(CNVIII) nuclei.
Image more superiorly at level of middle cerebellar
peduncles shows midline vermis & nodulus. Nodulus, just
posterior to 4th ventricle, is occasionally mistaken for a
lesion in 4th ventricle. Middle cerebellar peduncle (brachium
pontis) connects pons with cerebellum & contains
corticopontine tracts. It is a common location for multiple
sclerosis plaques.
This image shows superior cerebellar peduncles (brachium
conjunctivum), which connect cerebellum with red nucleus &
thalamus. Superior cerebellar hemisphere is supplied
primarily by superior cerebellar arteries, which arise from
basilar artery just before posterior cerebral arteries, which
are terminal branches. Superior cerebellar arteries also
supply superior cerebellar peduncle, dentate nucleus, & part
of middle cerebellar peduncle.
Image more superiorly shows midline vermis.
7T CORONAL T2 MR
First of 6 coronal T2 MR images at 7T from posterior to
anterior shows primary (tentorial) fissure, which is deepest
fissure on superior (tentorial) surface of cerebellum. Other
main fissure is horizontal (petrosal) fissure, which extends
from middle cerebellar peduncle on anterior (petrosal)
surface posterolaterally onto inferior (suboccipital) surface
of cerebellum.
Image more anteriorly shows dentate nucleus, which
receives cortical fibers of cerebellar hemispheres & sends
fibers through superior cerebellar peduncles to red nucleus
& thalamus. Other cerebellar nuclei are midline &
paramedian & are not resolved on conventional and
ultrahigh field imaging.
This image shows the 4th ventricle, laterally delimited by the
superior cerebellar peduncles.
Image more anteriorly shows nodulus projecting into 4th
ventricle. Superior cerebellar peduncle is seen along
superior 4th ventricle as it extends to superior pons &
midbrain to send fibers to red nucleus & thalamus.
This image shows horizontal (petrosal) fissure curving
anteriorly onto anterior (petrosal) surface of cerebellum.
Surface of cerebellum exhibits numerous narrow, almost
parallel convolutions called folia. Cerebellar hemispheres
contain lobules or wings that are paired with vermis lobules.
Image more anteriorly shows middle cerebellar peduncles &
cerebellar tonsils. Flocculus & nodulus make up
flocculonodular lobe of cerebellum. Flocculus is a common
pseudolesion in CPA cistern. Inferiorly, cerebellar
hemispheres are separated by a deep vallecula, which
contains falx cerebelli. Vallecula is bounded by tonsils
bilaterally.
7T SAGITTAL T2 MR
First of 6 sagittal T2-SPACE MR images at 7T from lateral
to medial shows white matter core of cerebellum, which
branches into medullary laminae, which occupy central
lobules & are covered by cerebellar cortex. In sagittal
section, the highly branched pattern of medullary laminae is
known as arbor vitae (tree of life). Cerebellar nuclei are
located deep in white matter, but only dentate nucleus is
resolved on imaging.
Image through lateral cerebellar hemisphere shows superior
(tentorial), inferior (suboccipital), & anterior (petrosal)
surfaces. Dentate nucleus has a folded band appearance
with medial part remaining open (hilum of dentate nucleus).
Image more medially shows relationship of cerebellum to
brainstem. Note middle cerebellar peduncle connects
cerebellum to pons.
This image shows quadrigeminal plate cistern, anterior &
superior to cerebellum.
Slightly off-midline image shows major fissures. Primary
(tentorial) fissure separates anterior culmen from posterior
declive. Horizontal (petrosal) fissure separates folium above
from tuber below. Prebiventral/prepyramidal (suboccipital)
fissure separates posterior tuber from anterior pyramid.
Superior cerebellar cistern is above cerebellum, below
tentorium.
Midline image shows components of vermis. Superior
vermis includes lingula, central lobule, culmen, declive, &
folium from anterior to posterior. Horizontal (petrosal)
fissure separates superior from inferior vermis. Inferior
vermis includes tuber, pyramid, uvula, & nodulus from
superior to inferior. Cerebellum forms roof of 4th ventricle
with superior & inferior medullary velum.
Cerebellopontine Angle/IAC
Main Text
T ERM INOLOGY
Abbreviations
• Cerebellopontine angle (CPA) and internal auditory canal

(IAC)
Definitions
• CPA-IAC cistern : CSF space in CPA and IAC containing

CNVII and CNVIII and anterior inferior cerebellar artery
(AICA) loop
• IAC fundus : Lateral CSF-filled cap of IAC cistern
containing distal CNVII, superior vestibular nerve (SVN),
inferior vestibular nerve (IVN), and cochlear nerve
• Cochlear aperture : Bony opening connecting IAC fundus to
cochlea
IMAGING ANATOMY
Internal Contents
• Vestibulocochlear nerve (CNVIII) : CPA-IAC cistern

Components
– Vestibular (balance) and cochlear portions (hearing)
Cochlear nerve portion, CNVIII course
– Leaves spiral ganglion as auditory axons
– Travels as cochlear nerve in anterior-inferior
quadrant of IAC
– Joins SVN and IVN at porus acusticus to become
CNVIII bundle in CPA cistern
– Crosses CPA cistern as posterior nerve bundle to
enter brainstem at pontomedullary junction
– Enters brainstem, bifurcates to synapse with both
dorsal and ventral cochlear nuclei
CNVII and CNVIII orientation in IAC cistern
– "Seven-up, coke down" useful mnemonic
– CNVII anterosuperior; cochlear nerve anteroinferior
– SVN posterosuperior; IVN posteroinferior in IAC
• Facial nerve (CNVII): CPA-IAC cistern
Root exit zone in pontomedullary junction
Travels anterior to CNVIII in CPA cistern
Anterosuperior in IAC cistern
• AICA loop
Arises from basilar artery then rises into IAC
Continues in IAC as internal auditory artery (IAA)
May mimic cranial nerve on high-resolution T2
IAA supplies 3 branches to inner ear
• Other structures in CPA cistern
Flocculus of cerebellum in posteromedial CPA
Choroid plexus may pass from 4th ventricle though
foramen of Luschka into CPA cistern
• Other structures in IAC cistern
Crista falciformis (horizontal crest): Horizontal bony
projection from IAC fundus
Vertical crest (Bill bar): Vertical bony ridge in superior
portion IAC fundus (not visible on CT or MR)
Cochlear aperture : IAC outlet for cochlear nerve to
cochlea
Macula cribrosa : Perforated bone between IAC and
vestibule of inner ear

Imaging Approaches
• Cochlear portion of CNVIII

Principal impetus for imaging CNVIII
Bone CT used in trauma, otosclerosis, and Paget disease
MR used for all other indications
• MR imaging approach to uncomplicated unilateral
sensorineural hearing loss (SNHL)
Screening MR involves high-resolution thin-section T2
MR imaging through CPA-IAC
• MR imaging approach to complex SNHL (unilateral SNHL +
other symptoms)
Whole-brain and posterior fossa sequences
Begin with whole-brain axial T2 and FLAIR sequences
Conclude with axial and coronal T1 thin-section C+ MR
of posterior fossa and CPA-IAC
Imaging Pitfalls
• Normal variants in CPA-IAC

Normal structures, when unusually prominent, trouble
radiologist evaluating CPA-IAC
AICA loop flow void on high-resolution T2 MR
– Will not prominently enhance on T1 C+ MR
– Subtle enhancement in IAC on T1 C+ MR may be
mistaken for small acoustic schwannoma
Marrow space foci in walls of IAC can mimic IAC tumor
on T1 C+ MR images
– Correlate location of foci with IAC cistern
– Bone CT of T-bone may be necessary to identify this
normal variant
Function Dysfunction
• CPA-IAC lesions most commonly present with SNHL

Uncomplicated unilateral SNHL : Patient otherwise
healthy and presents with unilateral SNHL
Complicated SNHL : Patient has other symptoms in
addition to unilateral SNHL
– Symptoms include other cranial neuropathy, long
tract signs, and headache
• Cochlear nerve injury
SNHL and tinnitus primary symptoms
• Facial nerve injury, CPA-IAC portion
Peripheral facial neuropathy
– Lacrimation, stapedial reflex, anterior 2/3 tongue
taste loss, and complete loss of muscles of facial
expression on side of lesion
– CNVII rarely injured by lesion in CPA-IAC
– If lesion in CPA-IAC and CNVII is out, consider
nonacoustic schwannoma causes, such as facial
nerve schwannoma or metastatic disease
EMBRYOLOGY
Embryologic Events
• IAC forms separately from inner ear and external ear

• Forms in response to migration of CNVII and CNVIII
through this area
Image Gallery
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GRAPHICS
Graphic shows cerebellopontine angle (CPA)-internal

auditory canal (IAC) cisterns and inner ear. The inferior and
superior vestibular nerves begin in cell bodies in the
vestibular ganglion, from there coursing centrally to 4
vestibular nuclei. The cochlear component of CNVIII begins
in bipolar cell bodies in the spiral ganglion of the modiolus.
Central fibers run in the cochlear nerve to dorsal and ventral
cochlear nuclei in the inferior cerebellar peduncle.
Axial graphic of magnified cochlea shows the modiolus and
cochlear nerve in the IAC fundus. Note that cells in the spiral
ganglion are bipolar contributing proximal axons that
constitute the cochlear nerve and distal fibers to the organ
of Corti.
Graphic depicts the fundus of the IAC. Notice that the crista
falciformis separates the cochlear nerve and inferior
vestibular nerve below from CNVII and superior vestibular
nerve above. Also note the vertical crest separating CNVII
from the superior vestibular nerve.
AXIAL BONE CT
First of 3 axial bone CT images of the left ear through the
IAC presented from superior to inferior is shown. In this CT
image, the labyrinthine segment of the facial nerve is seen
exiting the anterosuperior fundus of the IAC.
In this image, the cochlear aperture is seen connecting the
anteroinferior fundus of the IAC to the cochlea. The
cochlear nerve accesses the modiolus of the cochlea
through this aperture. Note the posterolateral fundal bony
wall abutting the medial vestibule. Multiple branches of the
vestibular nerves pass to the vestibule and semicircular
canals through this wall called the macula cribrosa.
The cochlear modiolus is visible as a high-density structure
at the cochlear base directly inside the cochlea from the
cochlear aperture. The high jugular bulb projects cephalad
behind the IAC.
3T SAGITTAL T2 MR
First of 3 oblique sagittal high-resolution T2 MR images
presented from lateral to medial shows the fundus of the
IAC filled with high-signal CSF. The horizontal low-signal line
in the fundus is the crista falciformis. The facial nerve is
anterosuperior while the cochlear nerve is anteroinferior.
In this image through the mid-IAC, the 4 discrete nerves are
well seen. Notice that the anteroinferior cochlear nerve is
normally slightly larger than the other 3 nerves in the IAC.
At the level of the porus acusticus, the facial nerve is visible
just anterior to the vestibulocochlear nerve. The overall
appearance of these 2 nerves is that of a "ball" (facial
nerve) in a "catcher's mitt" (vestibulocochlear nerve). The
vestibulocochlear nerve contains the cochlear, inferior, and
superior vestibular nerves.
3T AXIAL T2 MR
First of 3 axial T2 MR images presented from superior to
inferior reveals the porus acusticus, midportion, and fundus
of the IAC on the right. On the left, the anterior inferior
cerebellar artery is seen looping through the CPA cistern.
Also note the facial nerve and superior vestibular nerve on
the left within the IAC.
In this image, the facial nerve and superior vestibular nerve
are seen in the right IAC while the cochlear nerve and
inferior vestibular nerve are visible on the left.
In this image, the cochlear nerve is seen in the right IAC
exiting through the cochlear aperture to reach the modiolus
of the cochlea. On the left, the CPA is seen with the
vestibulocochlear nerve emerging from the brainstem at this
point.
3T CORONAL T2 MR
First of 3 coronal T2 MR images presented from posterior
to anterior through the CPA and IAC cisterns shows
important regional structures, including the preganglionic
segment of CNV, anterior inferior cerebellar artery loop,
flocculus of the cerebellum, and vertebral artery.
In this image, the crista falciformis in the fundus of the IAC
is seen. The facial nerve and superior vestibular nerve are
above, and the cochlear nerve and inferior vestibular nerve
are below the crista falciformis.
At the level of the cochlea, the anterior belly of the pons is
visible. The preganglionic segment of the trigeminal nerve is
in the anterosuperior portion of the CPA cistern while the
jugular tubercle is in the anteroinferior portion.
SECT ION 5
CSF SPACES
Outline

Ventricles and Choroid Plexus
Main Text
T ERM INOLOGY
Definitions
• Tela choroidea: Double layer of pia, formed during folding of

brain where hemispheres overgrow diencephalon &
cerebellum apposes dorsal brainstem
• Choroidal fissure: Narrow, pial-lined channel between
subarachnoid space (SAS) & ventricles; site of attachment of
choroid plexus in lateral ventricles
GROSS ANATOMY
Overview
• Cerebral ventricles
4 CSF-filled, ependymal-lined cavities deep within brain
Paired lateral, midline 3rd & 4th ventricles
Communicate with each other as well as central canal of
spinal cord, SAS
• Choroid plexus
Secretory epithelium that produces CSF
Choroid plexus forms where tela choroidea contacts
ependymal lining of ventricles: Roof of 3rd ventricle,
body & temporal horn of lateral ventricle via choroidal
fissure, inferior roof of 4th ventricle
CSF flows from lateral ventricles through foramen of
Monro into 3rd ventricle, through cerebral aqueduct
into 4th ventricle; exits through foramina of Luschka &
Magendie to SAS
Bulk of CSF resorption through arachnoid granulations
in region of superior sagittal sinus
• Lateral ventricles
Each has body, atrium, 3 horns
Frontal horn formed by
– Roof: Corpus callosum
– Lateral wall, floor: Caudate nucleus
– Medial wall: Septum pellucidum (thin midline
structure that separates right, left frontal horns)
Body formed by
– Roof: Corpus callosum
– Floor: Dorsal surface of thalamus
– Medial wall, floor: Fornix
– Lateral wall, floor: Body, tail of caudate nucleus
Temporal horn formed by
– Roof: Tail of caudate nucleus
– Medial wall, floor: Hippocampus
– Lateral wall: Geniculocalcarine tract, arcuate
fasciculus
Occipital horn : Surrounded by white matter (forceps
major of corpus callosum, geniculocalcarine tract)
Atrium : Confluence of horns; contains glomi of choroid
plexus
Lateral ventricles communicate with each other, 3rd
ventricle via Y-shaped foramen of Monro
• 3rd ventricle
Midline, slit-like vertical cavity between right, left
diencephalon that contains interthalamic adhesion (not
true commissure)
Borders
– Anterior: Lamina terminalis, anterior commissure
– Lateral: Thalami
– Roof: Tela choroidea, choroid plexus
– Floor: Optic chiasm, infundibulum & tuber
cinereum, mammillary bodies, posterior perforated
substance, tegmentum of midbrain
– Posterior: Pineal gland, habenular & posterior
commissures
Recesses
– Inferior: Optic, infundibular
– Posterior: Suprapineal, pineal
Communicates with 4th ventricle via cerebral aqueduct
• 4th ventricle
Diamond-shaped cavity (rhomboid fossa) along dorsal
pons & upper medulla
Borders
– Roof: Tent-shaped, covered by anterior (superior)
medullary velum above & inferior medullary velum
below
– Walls: Dorsal surface of pons & medulla, cerebral
peduncles (superior/middle/inferior)
5 recesses
– Paired posterior superior: Thin, flat pouch capping
tonsils
– Paired lateral: Curve anteriorly under brachium
pontis, contain choroid plexus, communicate with
SAS via foramina of Luschka
– Fastigium: Blind-ending, dorsally pointed midline
outpouching from body of 4th ventricle
Communicates with SAS via foramina of Magendie &
Luschka, with central canal of cord via obex
IMAGING ANATOMY
Overview
• Lateral ventricles: Paired, C-shaped, curve posteriorly from

temporal horns, arch around/above thalami
• 3rd ventricle: Thin, usually slit-like; 80% have central
adhesion between thalami (massa intermedia)
Recesses: Optic is rounded, superior to optic chiasm;
infundibular is pointed, extends inferiorly into
infundibular stalk; suprapineal is thin, extends over
pineal; pineal is pointed projecting into pineal stalk
• 4th ventricle: Diamond-shaped midline infratentorial
ventricle
Terminates inferiorly at obex, which communicates with
central canal of spinal cord (dorsal "bump" covering
obex is nucleus gracilis)
Normal Variants
• Ventricles: Cavum septi pellucidi, cavum vergae, cavum veli

interpositi
• Choroid plexus: Calcification, xanthogranulomas (glomi
appear lobulated, cystic)

Imaging Pitfalls
• Spin dephasing with pulsatile CSF flow can mimic

intraventricular mass (e.g., colloid cyst)
Image Gallery
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GRAPHICS
Schematic 3D representation of the ventricular system,

viewed in the sagittal plane, demonstrates the normal
appearance and communicating pathways of the cerebral
ventricles.
Sagittal midline graphic of normal midline ventricular
anatomy is shown. Choroid plexus from the lateral ventricles
(not shown) extends through the foramina of Monro and
curves dorsally and posteriorly along the roof of the 3rd
ventricle. Choroid plexus is not found in the frontal or
occipital horns of the lateral ventricles, the cerebral
aqueduct, or foramen of Magendie. The foramen of
Magendie is a slit-like median aperture, which allows
posterior communication of the 4th ventricle with the
cisterna magna. The obex is the inferior terminus of the 4th
ventricle in the upper cord.
3T AXIAL T2 MR
First of 12 sequential axial T2 MR images from inferior to
superior demonstrates the obex, which is the inferior
termination of the 4th ventricle in the upper cord. The obex
separates the central canal of the spinal cord from the
intracranial ventricular system.
Scan at the lower medulla demonstrates the foramen of
Magendie (median aperture), which allows communication
between the 4th ventricle and cisterna magna. In contrast to
the foramina of Luschka, the foramen of Magendie contains
no choroid plexus.
Image at the level of the medulla is shown. The 4th ventricle
communicates laterally with the medullary cisterns via the
foramina of Luschka as demonstrated here. Choroid plexus
in the foramina of Luschka normally protrudes through the
lateral recess into the medullary cisterns and should not be
mistaken for an enhancing mass.
Image at the level of lower pons demonstrates CNVII and
CNVIII as they traverse the cerebellopontine angle cistern
toward the internal auditory canals. The anterior inferior
cerebellar artery loop usually extends into the proximal
internal auditory canal.
Image through the body of the 4th ventricle shows the thin,
CSF-filled blind-ending posterior superior recesses capping
the tonsils.
Image at the level of the superior cerebellar peduncles
shows the normal-appearing upper 4th ventricle, which
begins at the inferior aspect of the cerebral aqueduct (of
Sylvius). Note the normally crescentic appearance of the
temporal horns also seen here, which are bounded medially
by the hippocampi. Rounding of the temporal horns should
raise suspicion for obstruction.
The suprasellar cistern and infundibular recess of the 3rd
ventricle are seen at this level. Note the normal thin
crescentic appearance to the temporal horns. The
hippocampi line the inner margins of the temporal horns.
Image at the midbrain level shows the lamina terminalis as a
thin tract of white matter crossing the midline at the anterior
margin of the 3rd ventricle. The cerebral aqueduct, barely
visible in this case, may have increased T2 signal (due to
CSF) or decreased signal (from high flow).
Image at the level of the anterior commissure, which forms
part of the anterior boundary of the 3rd ventricle, is shown.
Choroid plexus is normally present within the trigone
(atrium) of the lateral ventricle. Choroid plexus in the roof of
the 3rd ventricle is often hypoplastic or inapparent, even on
T1WI C+ MR scans.
Image at the foramina of Monro level shows connection
between the lateral and 3rd ventricles. Choroid plexus is
seen in the lateral ventricular atria. The occipital horns
contain no choroid plexus, and are a common place for
subtle intraventricular blood to collect dependently.
Image at the level of the lateral ventricular atria is shown.
Note the septum pellucidum, which separates the lateral
ventricles. Choroid plexus is normally seen in the
anteromedial body and atria of the lateral ventricles. The
caudate head impresses upon the floor and lateral wall of
the frontal horn, and the thalamus forms the lateral
boundary of the lateral ventricle body.
This image demonstrates normal choroid plexus in the
anteromedial body of the lateral ventricles. Note the normal
concavity along the lateral margins of the lateral ventricles
from the caudate nuclei.
3T CORONAL T2 MR
First of 12 sequential coronal T2 MR images from posterior
to anterior, through the ventricles, is shown. The normal
choroid plexus is seen in the trigone (atria) of the lateral
ventricles. The posterior superior recesses of the 4th
ventricle are partly imaged.
Normal choroid plexus is seen in the lateral ventricular atria.
The fornices, seen here, are thin white matter tracts with
complex communications with the hippocampus, thalamus,
hypothalamus, septal nuclei, and entorhinal cortex.
Anatomically, the fornix separates posteriorly into 2
posterior crura along the inferior surface of the corpus
callosum as seen here, then unites in the midportion (body)
and separates again anteriorly into the anterior columns
(pillars) that descend toward the mammillary bodies and
form the anterior border of the foramen of Monro.
Choroid plexus is seen here within the lateral ventricles. The
internal cerebral veins traverse normally within the cistern of
the velum interpositum, located superior to the pineal gland.
The lateral ventricles are separated in the midline by a thin
membrane(s), the septum pellucidum. Choroid plexus is
normally present in the lateral ventricle body, as again is
appreciated here. The caudate nuclei are located along the
lateral margins of the lateral ventricles, and form an
outwardly concave appearance.
Choroid plexus is normally seen within the temporal horn
and body of the lateral ventricle as appreciated here. Note
also the interpeduncular cistern, which should not be
confused with the 3rd ventricle on coronal scans. The
cisternal portions of the trigeminal nerves are well
demonstrated within the prepontine cisterns.
This image demonstrates normal choroid plexus in the roof
of the 3rd ventricle and body of the lateral ventricle. Note
the normal undulations along the superior aspect of the
hippocampal head, which are in contact with the temporal
horn.
The anterior temporal horns are well seen here. Note the
normally narrow transverse dimension of the 3rd ventricle;
when this configuration widens, or is outwardly convex,
concern for obstruction should be considered. Note also the
fornix again divides into 2 anterior columns at this level,
anterior to the foramina of Monro.
Image through the anterior 3rd ventricle, through the level of
the anterior commissure, which forms part of the anterior
boundary of the 3rd ventricle, is shown. The median
eminence of the hypothalamus forms part of the anterior
floor of the 3rd ventricle. The optic tracts are also well
demonstrated.
Image through the frontal horns of the lateral ventricles is
shown. The suprasellar cistern has the appearance of a 5-
point star at this level.
Image through the optic chiasm and frontal horns of lateral
ventricles is shown. The thin linear fluid collection inferior to
the frontal horns is the interhemispheric fissure, not the 3rd
ventricle. Note the presence of the anterior cerebral arteries
inferiorly within the interhemispheric fissure. This part of the
interhemispheric fissure is sometimes called the cistern of
the lamina terminalis.
The frontal horns of the lateral ventricles normally show
concave lateral margins. Note the slice is anterior to the
septum pellucidum; the midline white matter tract is the
genu of the corpus callosum. Choroid plexus is not present
in the frontal horns.
3T SAGITTAL T2 MR
First of 6 sagittal T2 MR images from lateral to medial,
through the temporal horn and atrium of the lateral ventricle,
demonstrates normal choroid plexus within the atrium. Note
also normal-appearing hippocampus along the inferior
margin of the temporal horn.
This image shows normal choroid plexus within the atrium
(collateral trigone) of the lateral ventricle. Choroid plexus is
not normally located within the occipital horns of the lateral
ventricle.
This image demonstrates normal choroid plexus within the
atrium (collateral trigone) of the lateral ventricle. Note the
normal cisternal portion the trigeminal nerve as it passes
anteriorly over the petrous ridge to enter the Meckel cave.
Image at the level of the cerebral peduncle demonstrates
choroid plexus within the body of the lateral ventricle. The
lateral wing of the 4th ventricle is seen.
Choroid plexus is seen within the body of the lateral
ventricle and inferior roof of 4th ventricle. Note also the
oculomotor nerve traversing the interpeduncular cistern.
This image demonstrates the normal choroid plexus in the
roof of the 3rd ventricle, the body of the lateral ventricle,
and the posterior roof of the 4th ventricle. The posterior
choroidal artery is seen passing forward into the 3rd
ventricle. The superior medullary velum and pons, which
form part of the 4th ventricle boundaries, are well seen. The
anteriorly located optic and infundibular recesses of the 3rd
ventricle are also well demonstrated. The lamina terminalis
forms the anterior border of the 3rd ventricle.
Subarachnoid Spaces/Cisterns
Main Text
T ERM INOLOGY
Abbreviations
• Subarachnoid spaces (SASs)
Definitions
• SASs: Cerebrospinal fluid-filled spaces between pia,

arachnoid; expand at base of brain, around brainstem,
tentorial incisura
• Liliequist membrane: Thin arachnoid membrane separates
suprasellar, interpeduncular, and prepontine cisterns
• Velum interpositum: Double layer of pia (tela choroidea),
result of folding of brain where hemispheres overgrow
diencephalon, forms velum interpositum, which may remain
open and communicate posteriorly with quadrigeminal
cistern (cavum veli interpositi)
• Choroidal fissure: Narrow, pial-lined channel between SAS
and ventricles; site of attachment of choroid plexus in lateral
ventricles
GROSS ANATOMY
Overview
• Numerous trabeculae, septa, membranes cross SAS →
create smaller compartments termed cisterns
Liliequist membrane separates suprasellar,
interpeduncular, and prepontine cisterns
Anterior/lateral pontine, medial/lateral pontomedullary
membranes separate posterior fossa cisterns
• All cranial nerves, major arteries/veins traverse cisterns
• All structures within cisterns invested with thin pial-like
layer of cells
• All SAS cisterns communicate with each other and with
ventricular system (through foramina of Magendie and
Luschka)
• Cisterns provide natural pathways for disease spread as well
as surgical approaches
• SAS cisterns divided into supra- and peritentorial,
infratentorial groups
• Sulci separate gyri, fissures separate hemispheres/lobes
IMAGING ANATOMY
Overview
• Supratentorial/peritentorial cisterns
Suprasellar cistern : Superior to pituitary gland
Interpeduncular cistern : Between cerebral peduncles,
Liliequist membrane
Ambient (perimesencephalic) cisterns : Wrap around
midbrain, connect suprasellar, quadrigeminal cisterns
Quadrigeminal cistern : Under corpus callosum
splenium, behind pineal gland, tectum; continuous
anteriorly with velum interpositum
Cistern of velum interpositum : Formed by double
layers of tela choroidea (pia), lies above 3rd ventricle;
communicates posteriorly with quadrigeminal cistern
• Infratentorial (posterior fossa) cisterns
Midline (unpaired)
– Prepontine cistern : Between upper clivus, anterior
pons
– Premedullary cistern : From pontomedullary
junction above to foramen magnum below; between
lower clivus and medulla
– Superior cerebellar cistern : Between upper vermis,
straight sinus
– Cisterna magna : Between medulla (anterior) and
occiput (posterior), below/behind inferior vermis
Lateral (paired)
– Cerebellopontine cistern : Between anterolateral
pons/cerebellum, petrous temporal bone
– Cerebellomedullary cistern (sometimes included as
lower cerebellopontine cistern): From dorsal margin
of inferior olive laterally around medulla
• Fissures
Interhemispheric fissure : Longitudinal cerebral fissure
separates hemispheres
– Inferior part contains cistern of lamina terminalis;
upper part contains pericallosal cistern
Sylvian (lateral) fissure : Separates frontal, temporal
lobes anteriorly, courses laterally to cover insula
Internal Contents
• Supratentorial/peritentorial cisterns
Suprasellar cistern : Infundibulum, optic chiasm, circle
of Willis
Interpeduncular cistern : Oculomotor nerves (CNIII),
basilar artery (BA) bifurcation, posterior
thalamoperforating arteries
Ambient cisterns : Trochlear nerves (CNIV), P2 posterior
cerebral artery (PCA) segments and branches, superior
cerebellar arteries (SCAs), basal veins of Rosenthal
Quadrigeminal cistern : Pineal gland, trochlear nerves
(CNIV), P3 PCA segments, medial and lateral posterior
choroidal arteries, vein of Galen (VofG) + tributaries
Cistern of velum interpositum : Internal cerebral veins
(ICVs), MPChAs
• Infratentorial cisterns
Prepontine cistern : BA, anterior inferior cerebellar artery
(AICA), CNV, and CNVI
Premedullary cistern : Vertebral arteries (VAs), anterior
spinal artery, posterior inferior cerebellar artery (PICAs),
CNXII
Superior cerebellar cistern : SCA branches, superior
vermian and precentral cerebellar veins
Cisterna magna : Cerebellar tonsils (often have dense
trabecular attachments), tonsillohemispheric PICA
branches
Cerebellopontine cistern : CNV, CNVII, and CNVIII;
AICA; petrosal vein
Cerebellomedullary cistern : CNIX, CNX, and CNXI
• Fissures
Interhemispheric fissure : Falx cerebri with inferior
sagittal sinus, anterior cerebral artery (ACA) and
branches
Lateral fissure : Middle cerebral artery (M1-3 segments)
and vein
Image Gallery
Print Images
GRAPHICS
Sagittal midline graphic demonstrates normal cisternal,
regional anatomy. The anterior circulation (anterior cerebral
arteries, posterior communicating arteries) have been
removed to illustrate some of the major structures in the
suprasellar cistern.
Sagittal midline graphic through the interhemispheric fissure
depicts subarachnoid spaces (SASs) with CSF (blue)
between the arachnoid (purple) and pia (orange). The
central sulcus separates the frontal lobe (anterior) from the
parietal lobe (posterior). The pia mater is closely applied to
the brain surface whereas the arachnoid is adherent to the
dura. The ventricles communicate with the cisterns and SAS
via the foramina of Luschka and Magendie. The cisterns
normally communicate freely with each other.
The membrane of Liliequist is a thin arachnoid membrane,
which can potentially obstruct CSF flow at the suprasellar
cistern; the sellar segment detailed here attaches inferiorly
along the dorsum sella. Superiorly, the membrane divides
into less constant segments: A superior diencephalic
membrane (attaches to mammillary bodies), and a posterior
mesencephalic membrane. Numerous small pial-lined
trabeculae are present throughout the SAS.
Detailed midline graphic of the pineal region demonstrates
the cistern of velum interpositum, which lies between double
layers of the tela choroidea and contains the internal
cerebral veins within its inferolateral margins. The
quadrigeminal cistern is posterior to the pineal gland; it
communicates posteriorly with the superior cerebellar
cistern and anteriorly with the cistern of the velum
interpositum.
3T AXIAL T2 MR
First of 9 sequential axial T2 MR images presented from
inferior to superior demonstrates the SASs and cisterns.
The cisterna magna is located behind the upper cervical
cord and lower medulla and below the cerebellar
hemispheres. It is continuous with the SAS of the spinal
cord. The vertebral arteries and posterior inferior cerebellar
arteries normally traverse the cisterna magna, as seen
here.
The cisterna magna is seen here as a small CSF-filled
space posterior to the cerebellum in the midline. The
vertebral arteries travel within the medullary cisterns.
The vertebral arteries are seen in the medullary cistern at
their confluence with the basilar artery.
CNVII and CNVIII are demonstrated traversing the
cerebellopontine cisterns. The anterior inferior cerebellar
arteries and posterior inferior cerebellar arteries also
course through this cistern. CSF in the Meckel cave
communicates freely with the prepontine and
cerebellopontine angle cisterns.
The basilar artery is seen in the prepontine cistern.
Cerebellar folia are seen here as numerous curvilinear fluid-
filled SASs over the cerebellum.
The pituitary infundibulum lies in the center of the
suprasellar cistern; the small fluid-filled structure centrally is
the variably hollow portion of the infundibulum, which is
contiguous with the infundibular recess. The ambient
cisterns surround the midbrain and connect the suprasellar
and quadrigeminal cisterns.
The quadrigeminal plate cistern is located between the
cerebellar vermis and the colliculi. Middle cerebral artery
branches are well demonstrated within the sylvian fissure.
The anterior commissure is only partly visualized on this
image, but demarcates the anterior aspect of the 3rd
ventricle. The interhemispheric fissure is visualized
anteriorly.
The sylvian and interhemispheric fissures are demonstrated
here. The retropulvinar cisterns are the lateral extensions of
the ambient cisterns, located posterior to the thalami. The
internal cerebral veins are located within the cistern of the
velum interpositum.
The parietooccipital sulci and interhemispheric sulci are
demonstrated here. The superior aspect of the cistern of
the velum interpositum is also visible.
3T CORONAL T2 MR
First of 12 coronal T2 MR images through the central
cisterns presented from posterior to anterior demonstrates
the posterior 3rd ventricle, interpeduncular, and
cerebellopontine cisterns. The vertebral arteries run within
the premedullary cisterns.
The oculomotor nerves traverse in the interpeduncular
cistern. Note the vertebrobasilar junction at the junction of
the prepontine and medullary cisterns.
The anterior vasculature within the prepontine cistern is well
seen here: The top of the basilar artery, which divides into
the posterior cerebral arteries, and the superior cerebellar
arteries. Duplication of the superior cerebellar artery, as
seen here, is a common anatomical variant. Note the
position of the oculomotor nerves, which travel between the
posterior cerebral and superior cerebellar arteries in the
interpeduncular cistern.
Image just anterior to basilar bifurcation shows confluence
of the suprasellar, interpeduncular, mesencephalic, and
prepontine cisterns.
The Liliequist membrane is seen at its lateral attachments
to/around the oculomotor nerves. The suprasellar cistern is
anterosuperior; interpeduncular is posterosuperior;
prepontine is posteroinferior.
The normal transverse appearance of the Liliequist
membrane is appreciated here; it is normally ~ 1/2 the width
of the 3rd ventricular floor. Laterally, the Liliequist
membrane attaches to the oculomotor nerves or the
arachnoid membranes around them. The interpeduncular
and suprasellar cisterns are thus separated anatomically
when this membrane is completely intact. Note also how the
hypothalamus forms part of the anterior floor of the 3rd
ventricle. Note also the midline crossing fibers of the
anterior commissure.
The anterior attachment of the Liliequist membrane to the
dorsum sellae is appreciated here. The suprasellar cistern
is seen above and surrounding the pituitary infundibulum.
The anterior recesses of the 3rd ventricle are seen here in
the midline: Optic and infundibular recesses. The lamina
terminalis, which forms part of the 3rd ventricle, is seen
here. A small CSF-filled extension of the suprasellar and
interpeduncular cisterns surrounds CNIII (oculomotor
nerve). CSF in the Meckel cave contains fascicles of the
trigeminal nerve (CNV) and communicates freely with the
prepontine cistern.
The suprasellar cistern is visualized here, above the pituitary
gland, surrounding the pituitary infundibulum and optic
chiasm.
The anterior circle of Willis vasculature is well seen in the
suprasellar cistern at this level with A1 and M1 segments
arising from the supraclinoid internal carotid arteries. The
proximal M1 segments are seen entering the sylvian
fissures.
The pituitary infundibulum is seen at the anterior inferior
insertion into the pituitary gland. The optic chiasm is seen in
the suprasellar cistern. The anterior cerebral arteries are
identified within the anterior interhemispheric fissure, and
the proximal middle cerebral arteries within the sylvian
fissures.
The optic nerves are seen separately in the anterior aspect
of the suprasellar cistern. The anterior curvature of the
anterior cerebral arteries is visualized in the
interhemispheric fissure, and middle cerebral artery within
the sylvian fissure.
3T SAGITTAL T2 MR
First of 6 sequential sagittal T2 MR images shown from left
to right demonstrates the internal cerebral veins traversing
the cistern of the velum interpositum. The quadrigeminal
cistern is posterior to the pineal gland and the collicular
plate.
This image demonstrates the membrane of Liliequist, a
delicate arachnoid membrane between the dorsum sella
and mammillary bodies, separating the prepontine,
interpeduncular, and suprasellar cisterns. Note how the thin
lamina terminalis and the anterior commissure form part of
the anterior 3rd ventricular margin. The cistern of the lamina
terminalis is seen anterior to the lamina terminalis.
Cisterns anterior to the brainstem and the superior
cerebellar cistern are well demonstrated here. Note the
course of the basilar artery, which travels in the prepontine
cistern.
The Liliequist membrane is again seen attaching
posterosuperiorly to the mammillary bodies and
anteroinferiorly to the dorsum sella. This small arachnoid
membrane may also require perforation when 3rd
ventriculostomies are performed to relieve obstruction when
anatomically complete.
The pericallosal artery, an A2 branch of the anterior
cerebral artery, is seen in the pericallosal cistern above the
corpus callosum. The oculomotor nerve is seen as it
emerges from the midbrain in the interpeduncular cistern.
The superior cerebellar cistern lies above the vermis and
cerebellar hemispheres and connects to the ambient and
quadrigeminal cisterns. The right stem of the foramen of
Monro is seen here. The cisterna magna is dorsal to the
cervicomedullary junction.
SECT ION 6
SKULL BASE AND CRANIAL
NERVES
Outline

Skull Base Overview
Main Text
T ERM INOLOGY
Abbreviations
• Skull base (SB)
Definitions
• SB: Complex osseous foundation of cranial vault, separates

intracranial structures from sinuses, orbits, & suprahyoid
neck (SHN)
• Transmits critical neurovascular structures between cranial
vault & SHN, orbits, sinuses
IMAGING ANATOMY
Overview
• 5 bones make up SB
Paired bones : Frontal & temporal bones
Unpaired bones : Ethmoid, sphenoid, & occipital bones
• 2 surfaces
Endocranial surface : Brain, pituitary, cisterns, cranial
nerves (CN), & intracranial vascular structures,
including cavernous sinuses
Exocranial surface : Extracranial head & neck
– Anterior portion: Nasal cavity, frontal & ethmoid
sinuses, orbits
– Central portion: Nasopharyngeal mucosal space,
masticator, parotid, & parapharyngeal spaces
– Posterior portion: Nasopharyngeal mucosal space,
carotid, retropharyngeal, perivertebral spaces
• 3 regions of SB
Anterior (ASB), central (CSB), & posterior (PSB)
– Assignment of borders between 3 regions is
somewhat arbitrary
– Boundaries are traditionally assigned on intracranial
surface of SB, viewed from above
– While this approach helps separate SB into 3 regions
for purposes of discussion, it does not satisfactorily
incorporate 3D structure of SB & may oversimplify
separation between regions
ASB
– Floor of anterior cranial fossa
– Anterolateral boundary: Frontal bones
– Inferior relationships: Nasal vault, ethmoid & frontal
sinuses; orbit & orbital canals
– Superior relationships: Frontal lobes, CNI
– ASB-CSB boundary: Lesser wing of sphenoid
(sphenoid ridge) & planum sphenoidale
Along posterior edge (limbus) of planum
sphenoidale, there is shallow sulcus or shelf
called chiasmatic sulcus
Chiasmatic sulcus runs transversely between
medial aspects of optic nerve canals & is
positioned between posterior edge of planum
sphenoidale & anterior border of sella
Some authors consider this part of ASB & some
consider this part of CSB
CSB
– Floor of middle cranial fossa
– Inferior relationships: Roof of pharyngeal mucosal
space, masticator, parotid, & parapharyngeal spaces
– Superior relationships: Temporal lobes, pituitary,
cavernous sinus, Meckel cave, CNI-CNIV, CNVI,
CNV1-3
– CSB-PSB boundary: Dorsum sella & posterior clinoid
processes medially, petrous ridges laterally
PSB
– Floor of posterior cranial fossa
– Inferior relationships: Posterior pharyngeal mucosal
space, carotid, retropharyngeal, perivertebral spaces
– Superior relationships: Brainstem, cerebellum,
CNVII-CNVIII, CNIX-CNXII, transverse-sigmoid
sinuses
– Posterior boundary: Occipital bone
Internal Contents
• ASB
Contents: Frontal, ethmoid bones, lesser wing, & planum
sphenoidale of sphenoid bone
Foramina & structures transmitted
– Cribriform plate : CNI, ethmoid arteries
– Optic canal : CNII, ophthalmic artery
– Foramen cecum : Midline, anterior to crista galli,
embryologic remnant of anterior neuropore
Typically involutes in early childhood
• CSB
Contents: Body & greater wing of sphenoid bone &
anterior temporal bones
– Superior orbital fissure : CNIII, CNIV, CNV1,
CNVI, & superior ophthalmic vein
Shares contents with ASB
– Inferior orbital fissure : Infraorbital artery, vein,
nerve
– Carotid canal : Internal carotid artery (ICA),
sympathetic plexus
– Foramen rotundum : CNV2, artery of foramen
rotundum, & emissary veins
– Foramen ovale : CNV3, lesser petrosal nerve,
accessory meningeal branch maxillary artery, &
emissary vein
– Foramen spinosum : Middle meningeal artery &
vein, meningeal branch of mandibular nerve
– Foramen lacerum : Not true foramen; cartilaginous
floor of anteromedial horizontal petrous ICA canal
– Vidian canal : Vidian artery & nerve
• PSB
Contents: Occipital & posterior temporal bones
– Internal auditory canal : CNVII, CNVIII,
labyrinthine artery
– Hypoglossal canal : CNXII
– Foramen magnum : Spinal portion CNXI, vertebral
arteries, & medulla oblongata
– Jugular foramen : Pars nervosa : CNIX, Jacobson
nerve, & inferior petrosal sinus
– Jugular foramen : Pars vascularis : CNX, Arnold
nerve, CNXI, jugular bulb, & posterior meningeal
artery

Questions
• SB imaging best done as combination of focused MR & CT

MR requires T1, T2, & T1 C+ with fat saturation
Bone CT defines bone changes
• SHN spaces/structures abut SB, allowing extracranial tumor
to access intracranial area via perineural tumor
Masticator space: CNV3
Parotid space: CNVII
Orbit: CNV1, CNIII, CNIV, & CNVI
Sinus & nose, pterygopalatine fossa: CNV2
• Bone CT
Axial thin slices (≤ 1 mm) with coronal/sagittal reformats
Edge-enhancing algorithm & wide window settings (>
2,000 HU) necessary to evaluate bony anatomy
Narrow windows (200-400 HU) & smoothing algorithm
to inspect regional soft tissues
If MR available, contrast unnecessary
• MR : Thin slices (≤ 4 mm), axial & coronal, T1, T2, & T1 C+
fat saturation
Precontrast T1 images use native fatty marrow for
"contrast"
Use MRA & MRV for arteries & veins
Imaging Pitfalls
• Prominent foramen cecum, accessory foramina can be

normal variants
• MR flow in jugular foramen may mimic mass
Image Gallery
Print Images
GRAPHIC
Graphic of the endocranial skull base viewed from above
with highlighted osseous landmarks labeled on the right is
shown. Important foramina are labeled on the left. The skull
base is formed by the frontal, ethmoid, sphenoid, temporal,
& occipital bones. The frontal, parietal, & occipital bones
form the lateral vault of the cranium. The skull base is an
undulating surface with grooves formed by the brain above
and rough bony structures providing dural attachments. The
lesser wing of the sphenoid & planum sphenoidale form the
anterior skull base-central skull base border, while the
petrous ridge & dorsum sella form the central skull base-
posterior skull base boundary. The majority of important
foramina are in the central skull base (sphenoid bone).
GRAPHICS
Graphic of the skull base viewed from below shows the

complexity of the exocranial skull base with bony landmarks
labeled on the left & foramina labeled on the right. Note that
in addition to the frontal, sphenoid, temporal, & occipital
bones, the undersurface of the skull base is formed by the
maxilla, vomer, palatine, & zygomatic bones. The ethmoid
bone is not part of the exocranial skull base.
Graphic of the skull base viewed from below shows the
relationships to the suprahyoid neck spaces & structures.
Four spaces have key interactions with the skull base:
Masticator, parotid, carotid, & pharyngeal mucosal spaces.
Parotid space (green) malignancy can follow CNVII into the
stylomastoid foramen. Masticator space (purple) receives
CNV3, while CNIX-CNXII enter the carotid space (red). The
pharyngeal mucosal space abuts the foramen lacerum,
which is covered by fibrocartilage in life.
AXIAL BONE CT
First of 12 axial bone CT images of the skull base
presented from superior to inferior is shown. At the level of
the orbital roof, the brain within the anterior, middle, &
posterior fossae is cradled above respective regions of the
skull base: Anterior skull base, central skull base, &
posterior skull base.
At the level of the upper sella, the lesser wings of the
sphenoid & planum sphenoidale, which demarcate the
anterior skull base-central skull base border, are barely
visible. More posterior, the petrous apices divide the central
skull base from the posterior skull base. The posterior skull
base houses the cerebellum, covered superiorly by
tentorium cerebelli, which attaches to posterior clinoid
processes.
At the level of the anterior clinoid, the optic canals pass
through the sphenoid bone, bounded by the anterior clinoid
process laterally & the sphenoid sinus medially. The dorsum
sella marks the anteromedial border of the posterior skull
base.
In this image, the crista galli superior tip is just visible. The
optic canal transmits CNII & the ophthalmic artery to the
orbit, while the superior orbital fissure transmits CNIII,
CNIV, CNV1, CNVI, & the superior ophthalmic vein. Note
the close approximation of the optic canal & superior orbital
fissure, separated by a thin, often pneumatized, optic strut.
The internal auditory canal is on the medial wall of the
temporal bone.
Crista galli provides an attachment for the falx cerebri &
divides the anterior aspect of the anterior skull base into 2
symmetric halves. Note that ethmoid air cells extend
superior to the cribriform plate. The sphenoid sinus is
immediately below the sella & medial to the superior orbital
fissure. The superior margin of petrooccipital fissure is
visible at medial tip of petrous apex. It is at this point where
the petrosphenoid ligament (Gruber ligament) can be found.
This short ligament spans the petrous ridge to the clivus.
Below the ligament is the Dorello canal that contains dural
venous structures & CNVI.
At the anterior base of the crista galli is foramen cecum
remnant. The petrooccipital fissure is the most common
location for skull base chondrosarcoma.
At the level of the upper clivus, the sphenooccipital
synchondrosis is visible, delineating the more anterior
basisphenoid from the more posterior basiocciput.
Posterolaterally, the petrooccipital fissure is seen
separating the more medial occipital bone from the more
lateral temporal bone.
At the level of the cribriform plate of the ethmoid bone, the
frontal, ethmoid, & sphenoid sinuses are all visible. Also
note the vertical & horizontal segments of the petrous
internal carotid arteries.
Notice the inferior orbital fissure is bounded by the sphenoid
sinus posteromedially & the greater wing of the sphenoid
bone laterally. It contains the infraorbital artery, vein, &
nerve. The foramen lacerum is occupied by cartilage & is
contiguous posteriorly with the petrooccipital fissure.
Inferiorly & posteriorly, the petrooccipital fissure contains
the inferior petrosal sinus.
At the level of the inferior orbital fissure & foramen
rotundum, the vidian canal is also seen. Foramen rotundum
provides a conduit for CNV2 to access the confluence of the
medial inferior orbital fissure & the superior pterygopalatine
fossa. CNV3 traverses the sphenoid bone via the foramen
ovale. The hypoglossal canal is seen in the inferior occipital
bone.
This image is at the level of the hypoglossal canal in the low
occipital bone. Anteriorly, the pterygomaxillary fissure is the
lateral opening of the pterygopalatine fossa.
At the inferior margin of the foramen magnum, the mastoid
tips are still visible. The pterygopalatine fossa is well seen,
connecting medially with the nasal cavity via the
sphenopalatine foramen & laterally with the masticator
space through the pterygomaxillary fissure. The foramen
rotundum & vidian canals also lead into the pterygopalatine
fossa.
3D-VRT BONE CT
3D-VRT of the osseous skull base from above is shown.
The anterior skull base is bounded by frontal bones
anteriorly & the lesser wing of the sphenoid & planum
sphenoidale posteriorly. The central skull base, with its
multitude of fissures & foramina, is made up of the sphenoid
bone & anterior temporal bone. It is bounded anteriorly by
the lesser wing of the sphenoid & posterior planum
sphenoidale & posteriorly by the dorsum sellae & petrous
ridge. The posterior skull base extends from the dorsum
sellae medially & petrous ridges laterally to the occiput
posteriorly.
3D-VRT of the osseous skull base from below highlights the
sphenoid bone with the foramen ovale & spinosum &
occipital bone with its occipital condyle. Notice the frontal
bone is not seen, but instead, maxillary, palatine, &
zygomatic bones are present anteriorly.
SAGITTAL BONE CT & 3T T1 MR

Paramedian sagittal bone CT through the anterior skull base
shows the intimate relationship of the skull base to the
paranasal sinuses. From anterior to posterior, note the
frontal & nasal bones, crista galli, cribriform plate
basisphenoid, & basiocciput. Notice that the sella is entirely
embedded in the sphenoid bone.
Paramedial sagittal T1 MR through the skull base shows the
anterior, central, & posterior skull bases. The anterior skull
base in this image is made up of the frontal bone, crista
galli, & cribriform plate of ethmoid bone. The crista galli is of
high signal secondary to fatty marrow. The central skull
base in the midline is often called the basisphenoid. It is
made up of the sphenoid bone-sinus & cradles the pituitary
gland. The sphenooccipital synchondrosis separates the
basisphenoid from the basiocciput of the posterior skull
base.
3T AXIAL T1 MR
First of 3 axial T1 MR images through the skull base from
superior to inferior shows the high-signal fatty marrow in the
crista galli. Adjacent to this are gyri recti of the frontal
lobes.
Image through the cavernous sinus reveals the ethmoid
sinuses in the ethmoid bones of the anterior skull base & the
sphenoid sinus in the sphenoid bone of the central skull
base. The petrous apex fatty marrow is of high signal with
the Meckel cave seen on its anterior margin.
At the level of the pterygopalatine fossa, the infraorbital
nerve can be seen exiting anterolaterally. The vidian canal,
another sphenoid bone structure, is visible connecting to the
medial pterygopalatine fossa. Middle meningeal artery &
CNV3 are noted passing through the foramen spinosum &
ovale, respectively. More posterolaterally, the carotid canal
& jugular foramen can be seen.
GRAPHIC & 3T T1 MR
Coronal graphic shows the important anatomy of the central
skull base/sphenoid bone. The cavernous portions of the
internal carotid arteries lie lateral & posterior to the sinuses.
At the orbital apex, the optic nerve can be seen traversing
the optic canal. Multiple cranial nerves pass through the
superior orbital fissure into the orbit, including CNs III, IV, &
VI, as well as the ophthalmic division on CNV. The maxillary
division of CNV in the foramen rotundum & vidian nerve are
positioned lateral & inferior to the sinus, respectively.
Coronal T1 MR at the level of the central skull base &
cavernous sinus shows the location of multiple cranial
nerves along the lateral cavernous sinus wall. The
oculomotor nerve (CNIII) is located within the oculomotor
cistern along the superior cavernous sinus. The abducens
nerve (CNVI) is the most medial cranial nerve, located
within the cavernous sinus proper & just lateral to the
cavernous carotid artery. The maxillary division of the
trigeminal nerve (CNV2) is the most inferior cranial nerve
within the lateral cavernous sinus wall.
CORONAL CT & 3T T1 MR
Coronal CT at the level of the sphenoid sinus & central skull
base shows the relationship of the optic canal superior &
medial to the superior orbital fissure. The coronal view also
nicely illustrates the locations of the foramen rotundum,
which contains the maxillary division of the trigeminal nerve
(CNV2) & the vidian canal, which contains the vidian artery
& nerve. Both the foramen rotundum & the vidian canal open
into the pterygopalatine fossa.
Coronal T1 MR shows the junction of the anterior & central
skull base with many important fissures & foramina. The
superior orbital fissure contains the oculomotor nerve
(CNIII), trochlear nerve (CNIV), the abducens nerve (CNVI),
& the ophthalmic division of the trigeminal nerve (CNV1), as
well as the ophthalmic vein. The foramen rotundum is
located superior & medial to the vidian canal, & both open
into the pterygopalatine fossa. The maxillary division of the
trigeminal nerve (CNV2) exits the skull base through the
foramen rotundum & continues as the infraorbital nerve into
the inferior orbit via the inferior orbital fissure.
Anterior Skull Base
Main Text
T ERM INOLOGY
Definitions
• Anterior skull base (ASB): Skull base anterior to lesser wing

of sphenoid (LWS) and planum sphenoidale
IMAGING ANATOMY
Overview
• ASB is floor of anterior cranial fossa and roof of nose,

ethmoid sinuses, and orbits
Forms broad, relatively flat floor of anterior cranial fossa
that predominantly houses frontal lobes of brain
• Bones forming ASB
Ethmoid : Cribriform plate and ethmoid sinus roof
centrally
Frontal : Orbital plate laterally
Sphenoid : Planum sphenoidale and lesser wing
posteriorly
• Boundaries of ASB
Anterolaterally: Frontal bone
Posteriorly: LWS and planum sphenoidale
• Relationships of ASB
Superior: Frontal lobes, CNI
– Inferior frontal lobe gyri include gyrus rectus medial
to olfactory sulcus, medial orbital gyrus, anterior
and posterior orbital gyri, and lateral orbital gyri
Inferior: Nasal vault and ethmoid sinus medially, orbit
laterally
Anterior: Frontal sinuses
Posterior: Posterior margins of ASB critically associated
with optic nerve canal, superior orbital fissure, and sella
Bony Landmarks of Anterior Skull Base
• Frontal crest : Anterior midline ridge between frontal bones;

falx cerebri attaches here
• Crista galli : Midline upward triangular process of ethmoid
bone; anteroinferior falx cerebri attaches here
Crista galli is pneumatized (contains mucosal-lined air
cell) in 10-15% of adults
Origin of pneumatization is extension of left or right
frontal air cell, not ethmoid sinus
• Cribriform plate (lamina cribrosa) : Horizontal perforated
bony plate of superomedial ethmoid
Forms part of nasal cavity roof
Forms floor of olfactory fossa (groove)
Shape and depth of olfactory fossa is variable and
depends on length of lateral lamella of cribriform plate
– Keros classification of olfactory fossa depth
Type I: < 3 mm
Type II: 4-7 mm
Type III: 8-16 mm
• Ethmoid roof (fovea ethmoidalis) : Horizontal or
downward-sloping projection from medial margin of orbital
plate
Ethmoid roof actually extension of orbital plate of frontal
bone
Medially, roof fuses with lateral lamella of cribriform
plate
Ethmoid roof forms superior bony margin of ethmoid
sinus air cells, separating ethmoid sinuses from anterior
cranial fossa
Appearance asymmetric > 50% of time
• Perpendicular plate of ethmoid : Midline sagittally oriented
bony plate that extends below level of cribriform plate and
forms superior portion of bony nasal septum
Appears contiguous with crista galli above
Fuses with vomer by 2 years of age
• Anterior clinoid process : Medial aspect of LWS; free edge of
tentorium cerebelli attaches here
Attaches to body of sphenoid by 2 roots
– Superior root forms roof of optic canal and merges
with planum sphenoidale
– Inferior root is optic strut and forms lateral and
inferior margin of optic canal
– Variant: Posterior inferior root attaches to sphenoid
bone, creating complete bony ring around
cavernous internal carotid artery
• LWS : Forms sphenoid ridge; separates anterior from central
skull base (CSB), forms superior boundary of optic nerve
canal
Medially, LWS forms superior boundary of optic nerve
canal
Laterally, LWS forms part of lateral superior margin of
superior orbital fissure
• Planum sphenoidale : Superomedial plate of sphenoid
bone, posterior to cribriform plate, anterior to tuberculum
sellae
Classic location for ASB meningioma
• Chiasmatic sulcus (prechiasmatic sulcus) : Horizontal
groove or shelf of variable depth and width just dorsal and
slightly inferior to posterior lip (limbus sphenoidale) of
planum sphenoidale and just anterior to upper lip of
tuberculum sella
Most authors would consider part of CSB
Lateral margins of groove merge with medial margins of
optic canals
Optic chiasm does not sit in sulcus; rather, chiasm is
posterior and superior to sulcus itself
Foramina and Fissures of Anterior Skull Base
• Foramen cecum
Transmits: Variably transmits small emissary vein from
nasal mucosa to superior sagittal sinus
Location: In margin between posterior aspect of frontal
bone and anterior aspect of ethmoid
Relationships: Small midline pit found immediately
anterior to crista galli
• Anterior ethmoidal artery foramen, canal, and sulcus
Transmits: Anterior ethmoidal artery, vein, nerve
– Anterior ethmoidal artery arises from distal
ophthalmic artery and passes anteromedially from
orbit to olfactory fossa
Anterior ethmoidal artery foramen: Small
funnel-shaped opening/notch along lamina
papyracea of orbit
Anterior ethmoidal groove or canal: Small
groove/channel through ethmoid sinus roof or
sinus proper; connects anterior ethmoid
foramen to ethmoid artery sulcus
Anterior ethmoidal artery sulcus: Small slit that
opens along lateral lamella of olfactory groove,
just lateral to cribriform plate
Location: Thin passageway between orbit to olfactory
groove
Relationships: Canal may pass through roof of ethmoid
sinus or be "exposed," passing through anterior ethmoid
sinus proper
– If ethmoid artery canal passes through ethmoid
sinus proper, it is vulnerable to injury during trauma
or surgery
• Posterior ethmoidal foramen, canal, and sulcus
Transmits: Posterior ethmoidal artery, vein, nerve
Location: Passes from posterior orbit, through ethmoid
roof, to lateral olfactory groove
Relationships: Medial sulcus just posterior to cribriform
plate, at seam between cribriform plate and planum
sphenoidale
• Foramina of cribriform plate
Transmits: Afferent fibers from nasal mucosa to olfactory
bulbs (CNI)
Location: ~ 20 perforations within cephalad ethmoid
bone plate
Relationships: Medial aspect of ethmoid, supports
olfactory bulbs
• Optic nerve canal
Dural-lined canal through LWS
Transmits optic nerve (CNII) and ophthalmic artery from
intracranial compartment to orbital apex
Anterior root of lesser wing forms roof of optic nerve
canal
Inferior root of lesser wing forms optic strut, variably
pneumatized pillar that forms inferolateral border of
optic nerve canal and separates canal from superior
orbital fissure
• Superior orbital fissure
Oblong defect in posterior orbital apex that provides
communication from orbit to cavernous sinus
Superior margin formed by LWS
Medial margin formed by optic strut
Inferior margin formed by greater wing of sphenoid
Transmits superior ophthalmic vein and nerves: CNV1
with branches (nasociliary, frontal, lacrimal), abducens (
CNIV ), trochlear ( CNVI ), superior and inferior
branches of oculomotor ( CNIII )
Development of Anterior Skull Base
• Overview
Skull base originates largely from cartilaginous
precursors
– Minimal contribution from membranous bone
> 100 ossification centers in skull base development
Ossifies posterior to anterior and lateral to medial
Ossification orderly and constant in first 2 years
– Does not correspond to exact age, however
• Birth : ASB develops primarily from cartilage with limited
ossification at birth
Early ethmoid air cells may be seen, but unossified crista
galli is faint
• 1 month : Ossification begins from ethmoidal labyrinth and
turbinates; proceeds medially
• 3 months : Roof of nasal cavity and tip of crista galli begin to
ossify
Ethmoid air cells still inferior to cribriform plate
• 6 months : Nasal roof well ossified; > 90% of infants have
partial ossification nasal roof on every coronal CT image
Perpendicular plate of ethmoid begins to ossify
Ethmoid sinus extends above cribriform plate plane
• 12 months : Crista galli well ossified; > 70% have ossified
posterior cribriform plate
• 18 months : Ethmoid air cells now extend above plane of
cribriform plate and orbital plates of frontal bones help form
early fovea ethmoidalis
• 24 months : Fovea ethmoidalis achieves more mature
appearance; perpendicular plate of ethmoid begins to fuse
with ossified vomer, most patients still have gap between
nasal and ethmoid bones
• > 24 months
ASB nearly completely ossified; small gaps persist in
nasal roof until early 3rd year
Foramen cecum ossifies as late as 5 years
Majority of cribriform plate and at least some of crista
galli should be ossified

Questions
• Pediatric
ASB ossification constant but variable in first 5 years
Understanding of normal development will avoid
confusion or misdiagnoses
Anterior neuropore closes in 4th gestational week
• Adult : Understanding critical relationships to ASB
necessary to fully evaluate region
Intracranial: Dura, inferior frontal lobe, olfactory bulb,
tuberculum sella, cavernous sinus
Extracranial: Nasal vault, frontal, ethmoid, sphenoid
sinuses, orbit and orbital apex, optic nerve canal,
superior orbital fissure
Many ASB lesions arise from frontal and ethmoid
sinuses, orbit and nose
• MR to search for anterior neuropore anomalies

• MR and CT complimentary in evaluation of ASB
abnormalities
Imaging Approaches
• Bone CT viewed at wide windows (> 2,000 HU)

• Reformat CT images at least 2 orthogonal planes
• High-resolution MR techniques necessary to evaluate
microanatomy of ASB
Imaging Pitfalls
• Pediatric
Apparent small gaps in ASB under age 3 are normal
Do not confuse nonossified foramen cecum for anterior
neuropore anomaly
– Foramen cecum ossifies last, typically by ~ 2 years
but may be as late as 5 years
• Adult
Beware: Fatty marrow in crista galli or ossified falx
cerebri is not pathology
Sinonasal lesions, including mucocele,
esthesioneuroblastoma, and carcinomas often extend
secondarily into ASB
Image Gallery
Print Images
GRAPHICS
Graphic of the anterior skull base (ASB) seen from above
shows olfactory bulb of CNI lying on the cribriform plate.
Neural structures have been removed on the right, allowing
visualization of numerous perforations in the cribriform plate,
through which afferent fibers from olfactory mucosa pass to
form the olfactory bulb. Note the foramen cecum, a small pit
anterior to the crista galli, bounded anteriorly by the frontal
bone, posteriorly by the ethmoid bone. The posterior margin
of the ASB is formed by the lesser wing of sphenoid (LWS)
and planum sphenoidale.
Sagittal graphic of the ASB shows midline vertical crista
galli. Anterior to the crista galli is the foramen cecum
remnant, and posterolateral to the crista galli is the
horizontal cribriform plate. The crista galli often shows MR
T1 hyperintensity in adults related to fatty marrow. The
planum sphenoidale is the posteromedial ASB.
Graphic shows a partially dissected ASB. Notice the
expansive dural covering that can give rise to meningiomas
in a variety of anterior locations. On the right side, the
cribriform plate, the ethmoid roof, orbital plate of the frontal
bone, LWS, and anterior clinoid process have been
resected. This exposes the ethmoid air cells, the superior
orbit, the optic nerve canal, and the superior orbital fissure.
The optic strut, often pneumatized, separates the optic
nerve canal medially from the superior orbital fissure
laterally and inferiorly. The cavernous sinus has also been
dissected, exposing CNIII, IV, and VI.
Graphic shows the anatomic relationships of the ASB from
below. On the left side, there has been dissection of ASB,
revealing the inferior frontal lobe (the orbital gyri), rectus
gyrus, and the olfactory nerve. On the right side, the
cribriform plate, roof of the ethmoid, and orbital roof are
seen from below.
Sagittal graphic shows normal ASB development. The
fonticulus frontalis, a small ASB fontanelle, is the normal
cartilaginous gap between developing, partially ossified
frontal and nasal bones. The prenasal space is also present
at this time as a dura-filled space between developing nasal
bones and cartilage of developing nasal capsule. Both sites
can become the location of a cephalocele.
Sagittal graphic shows the ASB slightly later in
development. The fonticulus frontalis has closed and
ossification of the chondrocranium has proceeded from
posterior to anterior. The prenasal space is now encased in
bone and becomes foramen cecum. A normal stalk of dura
extends through foramen cecum to skin (anterior
neuropore).
Sagittal graphic shows the ASB even later in development.
Anterior neuropore has regressed. Foramen cecum will
completely fuse by age 5.
AXIAL BONE CT
First of 9 axial bone CT images of the ASB from superior to
inferior is shown. This image is at the level of the orbital
roof. Notice that the medial aspect of the frontal lobes
extend more inferiorly than the lateral aspect. On this
image, the optic canal is seen passing medial to the anterior
clinoid process, lateral to the sphenoid sinus. The optic
canal is thin and can be obscured by volume averaging.
More inferiorly, the cephalad tip of the crista galli is seen in
the midline, where it and the frontal crest give attachment to
the falx cerebri. The superior orbital fissure and optic canal
are both visible.
In this image, the frontal, anterior, and posterior ethmoid
and sphenoid sinuses are all seen. Each sinus is named
based on the bone in the skull base where it forms.
At this level, the cephalad margin of the foramen cecum
remnant pit is visible just anterior to the crista galli. The
posterior ethmoidal foramen can be identified at the
posterior margin of the cribriform plate (not seen on this
image). Although not seen, the olfactory bulb is nestled
between the ethmoid sinuses and the crista galli.
In this image, the ethmoid air cells are laterally bounded by
the lamina papyracea, the paper-thin medial wall of the
orbit. The anterior ethmoidal foramen can also be seen
bilaterally along the lateral wall of the ethmoid sinuses. This
foramen contains the anterior ethmoidal artery, vein, and
nerve.
In this image, the posterior cribriform plate has come into
view. Notice the cribriform plate is inferomedial to the
ethmoid sinuses themselves.
In this image through the cribriform plate, the perforated
bone is visible. Notice the lateral lamella represents the
vertical bony wall of the ethmoid sinus that projects inferiorly
from the fovea ethmoidalis (ethmoid sinus roof) down to the
cribriform plate. This is far better seen on coronal sinus CT.
The cribriform plate has a variable relationship to the roof of
the ethmoid sinuses (fovea ethmoidalis). The more inferior
to the fovea ethmoidalis the cribriform plate is found, the
larger the dimension of the lateral lamella and the more
easily a sinus surgery complication may occur.
This image is just below the cribriform plate. The
perpendicular plate of the ethmoid bone is visible, as is the
olfactory mucosa in the olfactory recess of the nasal cavity.
The olfactory mucosa is the site of origin of
esthesioneuroblastoma.
CORONAL BONE CT
First of 6 coronal sinus bone CT images presented from
posterior to anterior shows the transition from central to
anterior skull base. Notice the optic canal medial to the
anterior clinoid processes. The inferior orbital fissure is
seen inferolateral to the optic canal. The planum
sphenoidale is the posterior sphenoid sinus roof.
Inferior to planum sphenoidale and lateral to the sphenoid
sinus is the complex anatomy of the orbital apex. The most
superomedial structure of the orbital apex is the optic canal,
divided from the superior orbital fissure by a small bony
spur called the optic strut. The optic canal is medial and
superior to the superior orbital fissure. The inferior orbital
fissure communicates inferiorly with the pterygopalatine
fossa.
At the level of orbital apex, the LWS is visible as the
posterior orbital roof. The planum sphenoidale is the
anterior roof of the sphenoid bone.
At the level of the posterior cribriform plate, the fovea
ethmoidalis is seen sloping gradually toward the midline. In
the midline, the cribriform plates themselves are visible.
At the level of the crista galli, it is possible to see the
multiple pieces of the ethmoid bone. The crista galli is the
most cephalad portion of the ethmoid bone, extending
directly inferiorly into the perpendicular plate of the ethmoid
bone. Just lateral to the base of the crista galli are the
cribriform plates, lateral lamellae, and fovea ethmoidalis
portions of the frontal bone.
In this image through the frontal bone and sinus, note the
anteroinferior nasal bone. Do not confuse the more
anterosuperior frontal crest (part of frontal bones) with
crista galli (part of ethmoid), not seen on this image.
AXIAL BONE CT DEVELOPMENT

Axial bone CT through the ASB in a newborn is shown. The
unossified gap between the nasal and frontal bones
normally contains dura at this age and represents the
regressing anterior neuropore. The areas of the foramen
cecum, crista galli, cribriform plate, and perpendicular plate
of the ethmoid bone are all normally unossified in the
newborn.
Axial bone CT through the ASB at 12 months is shown. The
crista galli is now well ossified. The foramen cecum area is
still not ossified. The foramen cecum is still open, but the
margins cannot be defined.
Axial bone CT through the ASB in an adult is shown. The
ethmoid air cells now extend far above the horizontal plane
of the cribriform plate. The crista galli is thickened and
heavily ossified. Although closed, the foramen cecum still
demonstrates a small remnant pit.
CORONAL BONE CT DEVELOPMENT

Coronal bone CT through the ASB in a newborn is shown.
The ASB is largely unossified, including crista galli,
cribriform plate, and perpendicular plate of ethmoid bone.
There is a large gap between the orbital plates of frontal
bones. Ethmoid air cells are not yet developed.
Coronal bone CT through the ASB at 12 months is shown.
The ethmoid bone is now mostly ossified, particularly crista
galli and posterior cribriform plate. Until 2-3 years of age,
unossified gaps in anterior cribriform plate and foramen
cecum (not shown) can be normal. Note developing lateral
lamella and fovea ethmoidalis are small.
Coronal bone CT through the ASB in an adult is shown. The
ASB is completely ossified. Ethmoid air cells extend
superolateral to the plane of the cribriform plate. Fovea
ethmoidalis is connected to the cribriform plate by lateral
lamella.
3T CORONAL T2 MR DEVELOPMENT
Coronal T2 MR through the ASB in a newborn is shown.
The ASB is poorly ossified at birth. The cartilaginous crista
galli and cribriform plate have intermediate signal intensity.
Coronal T2 MR through the ASB at 6 months is shown.
Notice the distance between the cribriform plate-fovea
ethmoidalis and the olfactory recess of the nose is enlarging
with the development of ethmoid sinuses.
Coronal T2 MR through the ASB at 12 months is shown.
The crista galli, cribriform plate, lateral lamella, and fovea
ethmoidalis are largely ossified at this age. As a result, the
ASB appears as low signal intensity from cortical bone.
Notice the ethmoid sinus aeration now projects cephalad to
the level of the crista galli base. The lateral lamella
connects the fovea ethmoidalis to the lateral cribriform
plate.
Coronal T2 MR through the ASB in an adult is shown. By
adulthood, there is a significant amount of high-signal fat in
the well-ossified crista galli. Gyri recti appear to extend far
more inferiorly than in childhood, because the ethmoid air
cells have enlarged superiorly.
3T SAGITTAL T1 MR DEVELOPMENT
Sagittal T1 MR of the ASB at 6 months is shown. The area
of cribriform plate/fovea ethmoidalis has begun to ossify,
hence the low-signal line. Foramen cecum margins are
difficult to discern as a result of absent ossification in the
area.
Sagittal T1 MR of the ASB at 18 months is shown. There is
rapid ossification of this area in the 1st year of life. Note
high-signal fatty marrow in crista galli. Foramen cecum is
visible anterior to the crista galli, normally containing a thin
dural stalk that will obliterate by 5 years of age.
Sagittal T1 MR of the ASB in an adult is shown. Crista galli
is readily visible due to its fatty marrow. Foramen cecum is
not seen because it is now fused. The frontal bone is
distinguishable from the nasal bone anteriorly.
3T SAGITTAL T2 MR DEVELOPMENT
Sagittal T2 MR of the ASB in a newborn is shown. The
chondrocranium is mostly intermediate signal intensity.
Large "gaps" of the ASB are seen because there is little
ossification, particularly anteriorly.
Sagittal T2 MR of the ASB at 18 months is shown. As ASB
progressively ossifies, crista galli becomes more
conspicuous. The frontal and sphenoid bones are higher
signal due to fatty marrow. Both the sphenoid and frontal
sinuses continue to pneumatize well into the teenage years.
Cribriform plate ossification is signaled by a dark line
anterior to the planum sphenoidale.
Sagittal T2 MR of the ASB in an adult is shown. The crista
galli is fully ossified and filled with high-signal fatty marrow.
The foramen cecum is fused and therefore not visible. The
sphenoid sinus is fully pneumatized.
Central Skull Base
Main Text
T ERM INOLOGY
Abbreviations
• Central skull base (CSB)
Definitions
• CSB: Skull base posterior to lesser wing of sphenoid

(LWS)/planum sphenoidale and anterior to petrous
ridge/dorsum sella
IMAGING ANATOMY
Overview
• CSB is floor of middle cranial fossa and roof of sphenoid

sinus and greater wing of sphenoid (GWS)
• Bones forming CSB
Sphenoid bone, basisphenoid, and GWS
Temporal bone anterior to petrous ridge
• Boundaries of CSB
Anterior boundary: Planum sphenoidale posterior
margin medially and LWS laterally
Posterior boundary: Dorsum sella medially and petrous
ridges laterally
• Relationships of CSB
Superior: Pituitary gland, cavernous sinus, Meckel cave,
CNI-IV, CNVI, CNV1-3, temporal lobe
Inferior: Anterior roof of pharyngeal mucosal space,
masticator, parotid, and parapharyngeal spaces
Bony Landmarks of Central Skull Base
• Sella turcica : Contains pituitary gland

Latin term for Turkish saddle
• Anterior clinoid processes : Extend from posterior and
medial aspect of LWS
Anteriorly and superiorly, merges with upper flat surface
of LWS
Anteriorly and inferiorly, merges with optic strut that
becomes lateral margin of optic canal
Variant: Posterior inferior strut fuses to sphenoid body
creating complete bony ring around cavernous internal
carotid
• Posterior clinoid processes : Extend posterolaterally off
dorsum sellae; attachment for tentorium cerebelli
Along posterior margin of CSB
• Chiasmatic sulcus : Shallow groove between posterior
margin of planum sphenoidale and tuberculum sella
Optic chiasm is not in sulcus but sits posterior and
superior to sulcus
Some authors prefer term "prechiasmatic sulcus" since it
is actually anterior to chiasm
Chiasmatic sulcus is shallow trough that extends
transversely between medial optic nerve canals
• Tuberculum sellae : Anterosuperior margin of sella turcica
Foramina and Fissures of Central Skull Base

• Optic canal
Transmits: CNII with dura, arachnoid and pia, CSF, and
ophthalmic artery
Formed by LWS, superomedial to superior orbital fissure
• Superior orbital fissure
Transmits: CNIII, CNIV, CNV1, CNVI, and superior
ophthalmic vein
Formed by cleft between LWS and GWS
Located inferior and lateral to optic canal
Superior orbital fissure is separated from optic canal by
optic strut, variably pneumatized extension from
sphenoid body
• Inferior orbital fissure
Transmits: Infraorbital artery, vein, and nerve ( CNV2 )
Formed by cleft between body of maxilla and GWS
• Carotid canal
Transmits: Internal carotid artery and sympathetic
plexus
Formed by GWS and temporal bone
• Foramen rotundum
Transmits: CNV2, artery of foramen rotundum, and
emissary veins
Completely within sphenoid bone; superolateral to
vidian canal
Provides direct connection to pterygopalatine fossa
• Foramen ovale
Transmits: CNV3, lesser petrosal nerve, accessory
meningeal branch of maxillary artery, and emissary vein
Completely within GWS
Provides direct connection to masticator space
• Foramen spinosum
Transmits: Middle meningeal artery and vein,
meningeal branch of CNV3
Within GWS, posterolateral to foramen ovale
• Foramen lacerum
Not true foramen
Between temporal and sphenoid bones
Cartilaginous floor of medial part of horizontal petrous
internal carotid artery canal
• Vidian canal
Transmits: Vidian artery and nerve (lacrimation)
Formed by sphenoid bone, inferomedial to foramen
rotundum
Provides direct connection to pterygopalatine fossa
Development of Central Skull Base
• CSB formed by > 25 ossification centers

• Ossification occurs from posterior to anterior
• Important ossification centers : Orbitosphenoids,
alisphenoids, pre- and postsphenoid, basiocciput
Orbitosphenoids → LWS, alisphenoids → GWS
Presphenoid and postsphenoid fuse at ~ 3 months
Postsphenoid and basiocciput fuse → clivus
• Sphenooccipital synchondrosis
Between postsphenoid and basiocciput
Responsible for most of postnatal skull base growth
One of last sutures of skull base to fuse
Open until 14 years, fuses by ~ 16 years in girls and ~ 18
years in boys
Variant Anatomy
• Persistent craniopharyngeal canal

Remnant of Rathke pouch
Vertical cleft in sphenoid body at site of fusion of pre-
and postsphenoid; just posterior to tuberculum sellae
area in adult
Extends from sella turcica to nasopharynx
• Extensive pneumatization of sphenoid sinus
Can cause endosinal vidian canals & foramen rotundum
Pneumatized clinoid processes
• Canaliculus innominatus
Variant canal for lesser superficial petrosal nerve, medial
to foramen spinosum
• Foramen of Vesalius
Transmits emissary vein from cavernous sinus to
pterygoid plexus; anterior to foramen ovale

Imaging Pitfalls
• Beware sphenoid MR signal changes

Sphenoid sinus: Low-signal cartilage until 2 years →
high-signal fat until 6 years → low-signal air (adult)
Clivus low signal until 25 years, then high-signal fat
• Do not confuse pneumatized clinoid processes with vascular
flow voids on MR
Image Gallery
Print Images
GRAPHICS
Graphic of the central skull base (CSB) from above shows
important nerves on the left. The numerous fissures and
foramina of the CSB are shown on the right. The greater
wing of the sphenoid forms the anterior wall and the floor of
the middle cranial fossa. The posterior limit of the CSB is
the dorsum sella medially and petrous ridge laterally.
Sagittal graphic through the central and anterior skull base
depicts the trigeminal nerve branches and exiting foramina.
The ophthalmic division of CNV exits into orbit via the
superior orbital fissure. The maxillary division of CNV exits
via the foramen rotundum to become the infraorbital nerve
and connects to the greater and lesser palatine nerves
inferiorly through the pterygopalatine ganglion to provide
sensation for the hard and soft palates. The mandibular
division of CNV exits through the foramen ovale then divides
into 2 main trunks, lingual and inferior alveolar nerves. Note
the vidian nerve in the vidian canal, a potential route of
perineural tumor from the pterygopalatine fossa to
intracranial structures.
Graphic of the CSB from above shows its many ossification
centers. Between the ossification centers of presphenoid is
a cartilaginous gap called the olivary eminence, which is
obliterated shortly after birth. A persistent cleft, called the
craniopharyngeal canal, can also be variably seen in
intersphenoid synchondrosis. Do not confuse these variants
with pathology.
Lateral graphic of the CSB shows major ossification centers
and the location of sutures. Intersphenoidal suture closes at
~ 3 months of age. At ~ 2 years of age, the presphenoid
begins to demineralize and become pneumatized.
Pneumatization progresses posteriorly into postsphenoid
until ~ 5-7 years of age. Sphenooccipital synchondrosis is
one of the last sutures to fuse at ~ 16 years of age. It is the
suture most responsible for growth of the skull base. The
basisphenoid is the upper ~ 1/3 of the clivus, and the
basiocciput is the lower ~ 2/3 of the clivus.
AXIAL BONE CT
First of 9 axial bone CTs of the CSB presented from
superior to inferior is shown. Note that the posterior clinoids
merge with the dorsum sella. The optic canal is bound by
the sphenoid sinus medially and the anterior clinoid process
laterally. Inferolateral to the optic canal is the superior
orbital fissure.
At the level of sella turcica, the superior orbital fissure is
seen as the medial opening of the orbit into the middle
cranial fossa. It lies below the optic canal, between the
greater wing of the sphenoid and the sphenoid sinus. The
sella turcica is bound by the dorsum sella posteriorly.
In this image, the body of the sphenoid bone is seen to be
made up of the sphenoid sinus, sella turcica, and dorsum
sella. Anterior to the sphenoid bone is the ethmoid bone.
In this image, the clivus can be seen forming the medial
posterior boundary of the CSB, while the petrous ridge
defines its lateral margin.
This image shows pneumatization of the sphenoid extending
up to the sphenooccipital synchondrosis, which is partly
unfused in this young adult. Note that the foramen rotundum
empties anteriorly into the pterygopalatine fossa, which
connects laterally with the masticator space through the
pterygomaxillary fissure.
At the level of the foramen rotundum, both pterygopalatine
fossae are clearly visible. The maxillary division of the
trigeminal nerve (CNV2) exits the skull base through the
foramen rotundum and continues as infraorbital nerve into
orbit via the inferior orbital fissure. Malignant tumors of the
skin of the cheek, orbit, and sinonasal area may all use
CNV2 as a perineural route to gain intracranial access.
In this image, the vidian canal is visible connecting the
pterygopalatine fossa anteriorly to the carotid canal floor
(foramen lacerum) posteriorly. A malignant tumor that has
accessed the pterygopalatine fossa may reach the carotid
canal of the skull base via perineural spread on the vidian
nerve in the vidian canal. There is a medial connection
between the pterygopalatine fossa and nose, the
sphenopalatine foramen. Juvenile angiofibroma begins along
the nasal margin of this foramen.
In this image, note that the foramen ovale is located in the
greater wing of the sphenoid bone. Extracranial perineural
malignancy on CNV3 enters the intracranial area via the
foramen ovale.
In this image, note the foramen spinosum is posterolateral
to the foramen ovale in the greater wing of the sphenoid
bone. The middle meningeal artery passes intracranially via
the foramen spinosum.
CORONAL BONE CT
First of 3 coronal bone CTs of the CSB presented from
posterior to anterior is shown. The foramen lacerum is seen
as a large defect between the greater wing of the sphenoid
bone and the sphenoid body. The foramen lacerum is not a
true foramen; it represents the cartilaginous floor of the
anteromedial horizontal segment of the petrous internal
carotid artery canal.
In this image, the foramen ovale is evident lateral to the
vidian canal and anterolateral to the foramen lacerum. It
transmits CNV3 from the middle cranial fossa to the
masticator space.
More anteriorly, the foramen rotundum and vidian canal are
both seen running in the transverse plane. Both the foramen
rotundum and vidian canal open into the pterygopalatine
fossa. Also note the pterygoid plates inferiorly.
3T AXIAL T1 C+ MR
First of 6 axial T1 C+ MR images of the CSB presented
from superior to inferior is shown. The enhancing venous
plexus of the cavernous sinus is seen surrounding the
cavernous internal carotid artery. Medially, the enhancing
pituitary gland in the sella turcica is bound by the dorsum
sella posteriorly and the sphenoid sinus anteriorly.
In this image, the upper basisphenoid part of the clivus is
seen. Cerebrospinal fluid-filled Meckel cave is seen along
the posterior border of the cavernous sinus.
In this image, the basiocciput part of the clivus is visible.
The upper clivus above the fused sphenooccipital
synchondrosis is part of the sphenoid bone, while the lower
clivus is part of the occipital bone. Notice the marrow space
of the clivus enhances.
Image through the superior pterygopalatine fossa shows its
anterolateral connection to the inferior orbital fissure. The
anteriorly projecting foramen rotundum can also be seen.
The sphenoid bone is partially pneumatized (sphenoid
sinus).
In this image, the maxillary nerve (CNV2) is seen as a linear
low-intensity structure in the foramen rotundum on the right.
On the left, this same nerve can be seen exiting the
foramen rotundum into the pterygopalatine fossa.
At the level of the foramen ovale, the mandibular nerve
(CNV3) is seen bilaterally. Also note the middle meningeal
artery passing through the foramen spinosum. The vidian
canal is clearly visible medial to the foramen ovale. The
clival occipital bone should be distinguished from the body
of the sphenoid bone, even though the sphenooccipital
fissure cannot be discerned.
3T CORONAL T1 MR AND T1 C+ MR
Coronal T1 MR through the anterior aspect of the CSB
shows the foramen rotundum containing CNV2 and the
vidian canal containing the vidian nerve and artery running in
the transverse plane. Both the foramen rotundum and vidian
canal open into the pterygopalatine fossa and are often
involved in perineural tumor spread.
Coronal T1 C+ FS MR through the CSB at the level of the
cavernous sinus shows multiple cranial nerves in the lateral
dural wall of the cavernous sinus. The oculomotor nerve
(CNIII) is the most superior nerve in the lateral cavernous
sinus wall. From superior to inferior are CNIII, CNIV, CNV1,
CNV2, and CNV3. The abducens nerve (CNVI) is the only
nerve located within the cavernous sinus proper, often just
lateral to the cavernous carotid artery. The mandibular
division of the trigeminal nerve (CNV3) is well seen as it
courses inferiorly through the foramen ovale to the
masticator space to supply the deep face musculature.
3T SAGITTAL T1 AND T2 MR DEVELOPMENT

Sagittal T2 MR of the CSB in a newborn shows the
important synchondroses of this area. The intersphenoidal
suture separates presphenoid from postsphenoid, while the
sphenooccipital synchondrosis separates postsphenoid
(basisphenoid) from the basiocciput.
Sagittal T1 MR shows the CSB at 6 months. The
intersphenoidal suture closes at ~ 3 months of age,
resulting in formation of the sphenoid body from the
presphenoid and postsphenoid. There is normal high-signal
fat within what used to be presphenoid. The sphenooccipital
synchondrosis will remain open until adolescence.
Sagittal T2 MR shows the CSB in an adult. Typically,
pneumatization extends throughout the entire sphenoid body
up to the fused sphenooccipital synchondrosis. The
sphenooccipital synchondrosis is one of last sutures of the
skull base to close. It fuses completely by ~ 16-18 years of
age.
GRAPHIC AND CLINICAL CORRELATION

Sagittal graphic shows the normal basisphenoid and
basiocciput, as well as the normal course of the notochord
in green. The intersphenoidal synchondrosis closes by 3
months. Two potential developmental anomalies are the
persistent craniopharyngeal canal and the persistent medial
basal canal. Lesions that arise along the extraosseous
notochord include Tornwaldt cyst, ecchordosis
physaliphora, and extraosseous chordoma.
Sagittal reformatted CT shows a bony tract originating in
the floor of the sella turcica extending to the roof of the
nasopharynx related to a persistent craniopharyngeal canal,
a developmental anomaly, posterior to the intersphenoidal
synchondrosis. Note the sphenooccipital synchondrosis
posteriorly and unfused in this child. (From DI3: H&N.)
Sagittal T2 MR in the same patient shows the persistent
craniopharyngeal canal as a small tract with central
intermediate signal and hypointense margins extending from
pituitary fossa to nasopharynx. Note the normal unfused
sphenooccipital synchondrosis, posterior to the
craniopharyngeal canal. (From DI3: H&N.)
Posterior Skull Base
Main Text
T ERM INOLOGY
Abbreviations
• Posterior skull base (PSB)
Definitions
• Skull base (SB) posterior to dorsum sella and petrous ridges
IMAGING ANATOMY
Overview
• PSB is made up of posterior temporal bones and occipital

bone and transmits CNVII-CNXII, medulla oblongata, and
jugular vein
• Bones of PSB
Temporal bones posterior to petrous ridges
Occipital bone (3 parts)
– Basilar part (basiocciput): Quadrilateral part anterior
to foramen magnum
– Condylar part (exoccipital): Occipital condyles here;
lateral to foramen magnum
– Squamous part : Large bony plate posterosuperior
to foramen magnum
• Boundaries of PSB
Anterior boundary: Dorsum sella medially and petrous
ridges laterally
Posterior boundary: Occipital bone
• Relationships of PSB
Inferior relationships: Posterior roof of pharyngeal
mucosal space, carotid, parotid, retropharyngeal,
perivertebral spaces, and cervical spine
Superior relationships: Brainstem, cerebellum, CNVII-
CNVIII, CNIX-CNXII, transverse-sigmoid sinuses
Bony Landmarks of Posterior Skull Base
• Petrous ridge of temporal bone

Divides central skull base from PSB
Attachment for fixed edge of tentorium cerebelli
• Jugular tubercle
Roof of hypoglossal canal seen well on coronal imaging
"Eagle's head" on coronal images is jugular tubercle
Foramina and Fissures of Posterior Skull Base
• Internal acoustic meatus (internal auditory canal)

Transmits: CNVII-CNVIII, labyrinthine artery
Opening in posterior wall temporal bone superior to
jugular foramen
Porus acusticus: Internal opening of internal acoustic
meatus
• Jugular foramen
2 parts: Pars nervosa and pars vascularis partially
divided by jugular spine
Between temporal and occipital bones
Carotid space extends directly up to jugular foramen
Pars nervosa
– Transmits CNIX, Jacobson nerve, and inferior
petrosal sinus
– Anteromedial but contiguous with pars vascularis
Pars vascularis
– Transmits CNX, Arnold nerve, CNXI, jugular bulb,
and posterior meningeal artery
– Larger than pars nervosa
• Groove for sigmoid sinus
Groove in medial mastoid temporal bone; cradles
sigmoid sinus
• Hypoglossal canal
Transmits: CNXII
Formed in condylar occipital bone
Inferomedial to jugular foramen
• Foramen magnum
Transmits: CNXI (cephalad component), vertebral
arteries, and medulla oblongata
Formed completely by occipital bone
• Stylomastoid foramen
Transmits: CNVII
Found in exocranial SB surface between mastoid tip and
styloid process
Extends directly into parotid space
Development of Posterior Skull Base
• Occipital bone has 4 major ossification centers around

foramen magnum
Supraoccipital, basioccipital, and paired exoccipital
• PSB is nearly completely ossified by birth
• Sutures of PSB remain unfused until 2nd decade
Intraoccipital sutures fuses between 8 and 16 years
Petrooccipital and occipitomastoid sutures are among
last to close (15-17 years)
• Kerckring ossicle
Small ovoid ossicle at posterior margin of foramen
magnum
Unfused and separate in 50% of term newborns
Kerckring-supraoccipital suture fuses by 1 year
Variant Anatomy of Posterior Skull Base
• Posterior condylar canal

Inconstant canal for emissary vein and meningeal branch
of ascending pharyngeal artery
One of largest emissary foramina of SB
• A symmetric petrous apices
Can contain high-signal fat or low-signal air
• Mastoid foramen
Variably transmits emissary vein from sigmoid sinus
• Persistent Kerckring ossicle

Questions
• PSB is largely ossified at birth, but PSB sutures are last in SB

to fuse
• PSB is intimately related to carotid and parotid spaces
• Bone CT with edge enhancement algorithm and wide

windows (> 2,000 HU)
• Use coronal imaging to examine normal "double eagles" of
hypoglossal canal and jugular foramen area
Hypoglossal canal along inferior margin of "eagle beak"
Imaging Pitfalls
• Watch for asymmetric petrous apex air &/or fat

• Beware of jugular foramen pseudolesion from MR flow
phenomenon
• Beware of open synchondroses/suture as pseudofracture
Image Gallery
Print Images
GRAPHICS
Graphic of posterior skull base as seen from above shows
the neural structures on the left, and the bony landmarks on
the right. The anterior boundary of the posterior skull base
is the clivus medially and petrous ridge laterally. The major
foramina are the foramen magnum, porus acusticus
(opening to the internal auditory canal), jugular foramen, and
hypoglossal canal. Notice that the jugular foramen connects
anteriorly with the petrooccipital fissure. The hypoglossal
canal is within the condylar occipital bone.
Coronal graphic of posterior skull base viewed from the
front shows the classic double eagle appearance in the
area of the hypoglossal canal. The jugular tubercle (eagle's
head and beak) separates the inferomedial hypoglossal
canal from the jugular foramen. The hypoglossal nerve is
found in the hypoglossal canal while CNIX-CNXI traverse
the skull base in the jugular foramen, CNIX in pars nervosa,
and CNX-CNXI in pars vascularis with the jugular vein.
GRAPHIC AND MR VENOGRAM

Graphic of major dural venous sinuses and jugular foramen
is seen from the top down. The midbrain and pons as well
as the left 1/2 of the tentorium cerebelli have been
removed. Notice the transverse sinus is in the wall of the
occipital bone while the sigmoid sinus is in the medial wall of
the temporal bone. The 2 portions of the jugular foramen
are also visible. The anterior pars nervosa receives the
glossopharyngeal nerve (CNIX) while the pars vascularis
has the vagus (CNX) and accessory (CNXI) nerves passing
through it.
Coronal view of MR venogram shows the transverse
sinuses feeding through the sigmoid sinuses into the jugular
foramen. The jugular bulb connects inferiorly with the
internal jugular vein of the carotid space. The slight
asymmetry of transverse sinuses is normal.
AXIAL BONE CT
First of 9 axial bone CT images, presented from superior to
inferior, shows the dorsum sella and the petrous temporal
bone as the anterior margin of the posterior skull base.
Posteriorly, the midline is demarcated by the bony internal
occipital crest, which provides attachment for the falx
cerebelli. The porus acusticus is the most superior foramen
of the posterior skull base and transmits CNVII and CNVIII.
At the level of the midcochlea, the posterior cranial fossa is
completely divided from the middle cranial fossa by the
clivus and petrous temporal bone. Laterally, the sigmoid
plate separates the mastoid air cells from the sigmoid sinus.
The jugular bulbs are visible bilaterally.
At the level of the midjugular foramen, note smaller
anteromedial pars nervosa (CNIX, Jacobsen nerve, inferior
petrosal sinus) and larger pars vascularis (jugular bulb,
Arnold nerve, CNX, and CNXI) separated by the jugular
spine.
Image of posterior skull base shows the sphenooccipital
synchondrosis, the petrooccipital fissure, and the
occipitomastoid suture all in the same plane. The
sphenooccipital synchondrosis has not yet fused in this
young adolescent.
Image through the jugular tubercle of the clivus is made up
almost completely of anterior occipital bone. The upper ~
1/3 of the clivus is above the sphenooccipital synchondrosis
and is therefore part of the sphenoid bone (basisphenoid).
In this image, the lower clivus (below the sphenooccipital
synchondrosis) is clearly made up of occipital bone
(basiocciput). The petrooccipital fissure separates the
temporal bone from the occipital bone and is the origin of a
chondrosarcoma of the skull base. The occipitomastoid
suture separates the mastoid sinus from the squamosal
portion of the occipital bone.
This image passes directly through the hypoglossal canal
and stylomastoid foramen. This canal transmits only the
hypoglossal nerve. Notice that as soon as the nerve exits
the hypoglossal canal, it immediately enters the
nasopharyngeal carotid space to join the glossopharyngeal
(CNIX), vagus (CNX), and accessory (CNXI) cranial nerves.
In this image, the inferior margin of the hypoglossal canal
runs within the occipital bone, between the basilar (clival)
and condylar portions. The inferior surface of the condylar
occipital bone are the occipital condyles.
In this image through the occipital condyle, the inferiormost
junction of the basilar (clival) occipital bone and the condylar
occipital bone is visible. The occipital condyles rest the
cranium upon the lateral masses of atlas (C1 vertebral
body).
CORONAL BONE CT
First of 6 coronal bone CT images of the left posterior skull
base, presented from posterior to anterior, is shown. The
hypoglossal canal passes through the condylar (lateral)
portion of the occipital bone. In the coronal plane with both
sides visible, this area has been referred to as the "double
eagle." Notice that the eagle's head and beak are the
jugular tubercle.
In this image through the mastoid (descending) portion of
the intratemporal facial nerve canal, the condylar part of the
occipital bone is outlined.
This image shows the classic "eagle" of the posterior skull
base with the "beak" of the jugular tubercle separating the
jugular foramen from the hypoglossal canal. Lesions of the
hypoglossal canal affect the undersurface of the "beak"
while lesions of the jugular foramen affect the external
surface of the "beak."
In this image of the left skull base and temporal bone,
notice both the hypoglossal canal and the jugular foramen
"empty" into the cephalad carotid space. The upper carotid
space therefore contains CNIX-CNXII as well as the internal
jugular vein.
In this image through the midinternal auditory canal, the
petrooccipital fissure is visible, separating the basioccipital
portion of the occipital bone from the temporal bone.
In this image through the condylar fossa of the
temporomandibular joint, the petrooccipital fissure is seen
between the basiocciput and the temporal bone. The
basiocciput is a large quadrilateral portion of the occipital
bone that extends anterosuperiorly from the anterior margin
of the foramen magnum to reach the sphenoid bone ~ 2/3
of the way up the clivus.
3T AXIAL T1 C+ FS MR
First of 3 axial T1 C+ FS MR images of the posterior skull
base, presented from superior to inferior, is shown. On the
patient's right, the high-signal enhancing sigmoid sinus can
be seen connecting anteromedially with the jugular bulb.
At the level of the hypoglossal canals, the hypoglossal
nerves can be seen as linear, low-intensity structures
surrounded by the enhancing high-signal basiocciput venous
plexus. The complex signal seen in both jugular bulbs should
not be mistaken for a lesion.
At the level of the foramen magnum, the internal jugular vein
and internal carotid artery of the carotid space are visible.
The vertebral arteries, medulla oblongata, and inferior
cerebellar tonsils are normally seen at this level.
3T CORONAL T1 C+ MR
First of 3 coronal T1 C+ MR images of the posterior skull
base, presented from posterior to anterior, shows the
jugular bulb within the jugular foramen. The low-signal
hypoglossal nerve is seen just below the "eagle's head" in
the hypoglossal canal. The high-signal perineural
basiocciput venous plexus is visible surrounding the
hypoglossal nerve.
In this image, the classic "double eagle heads" are visible
(jugular tubercles) with the hypoglossal nerve seen exiting
the inferior hypoglossal canal. As in this case, the jugular
bulbs are often asymmetric in size.
In this image, the anterior jugular tubercle can be seen
meeting the inferior basiocciput. The jugular bulb has
connected inferiorly with the internal jugular vein. The
internal jugular vein is within the nasopharyngeal carotid
space.
Additional Images
Presphenoid (green), postsphenoid with basisphenoid
(yellow), basiocciput (red), foramen cecum , and
intersphenoid synchondrosis are shown.
Cranial Nerves Overview
Main Text
T ERM INOLOGY
Abbreviations
• Olfactory nerve (CNI)

• Optic nerve (CNII)
• Oculomotor nerve (CNIII)
• Trochlear nerve (CNIV)
• Trigeminal nerve (CNV)
• Abducens nerve (CNVI)
• Facial nerve (CNVII)
• Vestibulocochlear nerve (CNVIII)
• Glossopharyngeal nerve (CNIX)
• Vagus nerve (CNX)
• Accessory nerve (CNXI)
• Hypoglossal nerve (CNXII)
IMAGING ANATOMY
Overview
• Cranial nerve groupings based on area of brainstem origin

Diencephalon: CNII
Mesencephalon (midbrain): CNIII and CNIV
Pons: CNV, CNVI, CNVII, and CNVIII
Medulla: CNIX, CNX, CNXI, and CNXII
• Best imaging modality for any simple or complex cranial

neuropathy is MR
Single exception to this directive is distal vagal
neuropathy where it is necessary to image to
aortopulmonic window on left
– CECT better here as less affected by breathing,
swallowing, and coughing movements
• If lesion located in bony area, such as skull base, sinuses, or
mandible, bone CT highly recommended to provide
complementary bone anatomy and lesion-related
information
Contrast enhancement of CT is not necessary if full T1,
T2, and T1 C+ MR available
Imaging Approaches
• Remember: Cranial nerves do not stop at skull base

• Radiologist must image entire extent of affected cranial
nerve
CNI, CNII, CNIII, CNIV, and CNVI : Include focused
orbital sequences
CNV : Include entire face to inferior mandible if V3
affected
CNVII : Include CPA, temporal bone, and parotid space
CNVIII : Include CPA-IAC and inner ear
CNIX-XII : Include basal cistern, skull base,
nasopharyngeal carotid space
– CNX : To fully evaluate for recurrent laryngeal nerve
lesion, follow carotid space to aortopulmonic
window on left, cervicothoracic junction on right
– CNXII : Remember to reach hyoid bone to include
distal loop as it rises into sublingual space
Imaging Pitfalls
• Do not forget to image extracranial structures associated

with cranial nerve affected
Clinical Importance
• Cranial nerves and their functions

Olfactory nerve ( CNI )
– Sense of smell
Optic nerve ( CNII )
– Sense of vision
Oculomotor nerve ( CNIII )
– Motor to all extraocular muscles except lateral
rectus (CNVI) and superior oblique (CNIV)
– Parasympathetic supply to ciliary and pupillary
constrictor muscles
Trochlear nerve ( CNIV )
– Motor to superior oblique muscle
Trigeminal nerve ( CNV )
– Motor (V3) to muscles of mastication, anterior belly
digastric, mylohyoid, tensor tympani and palatini
– Sensory to surface of forehead and nose (V1), cheek
(V2), and jaw (V3)
– Sensory to surfaces of nose, sinuses, meninges, and
external surface of tympanic membrane
(auriculotemporal nerve)
Abducens nerve ( CNVI )
– Motor to lateral rectus muscle
Facial nerve ( CNVII )
– Motor to muscles of facial expression
– Motor to stapedius muscle
– Parasympathetic to lacrimal, submandibular, and
sublingual glands
– Anterior 2/3 tongue taste ( chorda tympanic nerve )
– General sensation for periauricular skin, external
surface of tympanic membrane
Vestibulocochlear nerve ( CNVIII )
– Senses of hearing and balance
Glossopharyngeal nerve ( CNIX )
– Motor to stylopharyngeus muscle
– Parasympathetic to parotid gland
– Visceral sensory to carotid body
– Posterior 1/3 tongue taste
– General sensation to posterior 1/3 of tongue and
internal surface of tympanic membrane
Vagus nerve ( CNX )
– Motor to pharynx-larynx
– Parasympathetic to pharynx, larynx, thoracic and
abdominal viscera
– Visceral sensory from pharynx, larynx, and viscera
– General sensation from small area around external
ear
Accessory nerve ( CNXI )
– Motor to sternocleidomastoid and trapezius
muscles
Hypoglossal nerve ( CNXII )
– Motor to intrinsic and extrinsic tongue muscles
except palatoglossus
Image Gallery
Print Images
GRAPHICS, GLOBAL CRANIAL NERVES
Graphic shows all cranial nerves, viewing the brainstem

from below. Remember that CNIII-CNIV are associated
with the midbrain (mesencephalon), while CNV-CNVIII are
affiliated with the pons. CNIX-CNXII emerge from various
aspects of the medulla.
In this graphic of the skull base viewed from above, the
foramina are illustrated on the right and the associated
cranial nerves are illustrated on the left. The terminal
branches of CNI exit the skull base through many openings
in the cribriform plate of the ethmoid bone. CNII exits via the
optic canal, while CNIII, CNIV, CNVI, and CNV1 all go
through the superior orbital fissure. V2 traverses the
foramen rotundum, and V3 is seen exiting the foramen
ovale. CNVII and CNVIII are seen in the internal auditory
canal (IAC) with CNIX-CNXI found in the jugular foramen.
Finally, CNXII uses its own hypoglossal canal to leave the
basal cistern.
GRAPHICS, UPPER CRANIAL NERVES
Axial graphic shows the prepontine cistern and cavernous

sinus areas viewed from above. The preganglionic segment
of CNV can be seen in the lateral prepontine cistern,
entering the Meckel cave through the porus trigeminus.
CNIII, CNIV, and CNVI are seen piercing the dura to enter
the cavernous sinus. Only CNVI is within the venous
sinusoids of the cavernous sinus, while CNIII and CNIV
remain in its wall.
Coronal graphic shows the posterior view through the
cavernous sinus. The abducens nerve (CNVI) is the only
cranial nerve with a purely intracavernous course. CNIII and
CNIV enter the roof of the cavernous sinus. CNIII travels a
short distance in a tubular CSF-containing cistern before
becoming incorporated into the lateral wall of the sinus.
CNIV becomes immediately embedded in the lateral wall.
V1 and V2 are in the lateral wall of the cavernous sinus,
while V3 bypasses the cavernous sinus altogether.
Remember, sympathetic nerves travel along the
intracavernous internal carotid artery (ICA) as well.
GRAPHICS, LOWER CRANIAL NERVES

Graphic shows the frontal view of the brainstem and exiting
cranial nerves. CNIII is seen exiting the midbrain into the
interpeduncular cistern. CNIV wraps around the lateral
midbrain in the tentorial margin. CNVI exits at the
pontomedullary junction. CNVII and CNVIII exit the
brainstem at the cerebellopontine angle. Inferiorly, CNIX-
CNXI leave the lateral medulla in the postolivary sulcus.
CNXII exits via the preolivary sulcus.
Graphic shows the brainstem from behind, emphasizing the
lower cranial nerve nuclei. On the right are efferent fibers
and on the left are afferent fibers connecting to brainstem
nuclei. Highlights of this drawing include the nucleus
ambiguus providing voluntary motor fibers for CNIX and
CNX. The inferior salivatory nucleus provides secretomotor
fibers to the parotid via CNIX. The dorsal motor nucleus
provides involuntary motor and sensory fibers to CNX. The
solitary tract receives taste from CNVII and CNIX.
AXIAL BONE CT
First of 6 sequential axial bone CT images through the skull
base, presented from inferior to superior, shows the
foramina of sphenoid bone, including the foramen rotundum
(CNV2) and foramen ovale (CNV3). More posteriorly
oblique, the hypoglossal canal is visible bilaterally in the
occipital bone.
At the level of the inferior jugular foramen, the entry to the
vertical segment of the carotid canal is also seen just
anterior to the jugular foramen. Notice the ovoid shape of
the jugular foramen at this level. The floor of the
anteromedial aspect of the horizontal segment of the
petrous ICA is called the foramen lacerum.
At the level of the cribriform plate, the jugular foramen is
now divided by the jugular spine into the more anterior pars
nervosa (CNIX, Jacobsen nerve, and inferior petrosal sinus)
and the more posterolateral pars vascularis (CNX, CNXI,
Arnold nerve, and jugular bulb).
At the level of the midhorizontal portion of the petrous ICA,
the superior orbital fissure is seen. Remember that CNIII,
CNIV, and CNVI as well as the ophthalmic division of CNV
and the superior ophthalmic vein all enter the orbit through
this structure.
At the level of the cochlea and upper petrous apex, the
petrooccipital fissure is seen. This is approximately the
location of CNVI after it pierces the dura to leave the
prepontine cistern on its way to the cavernous sinus. On
bone CT, the area of the cavernous sinus can only be
approximated. Notice also the inferior margin of the porus
trigeminus.
The IAC is visible on this most cephalad CT image. The
facial (CNVII) and vestibulocochlear (CNVIII) nerves pass
through the IAC. The optic nerve (CNII) enters orbit via the
optic canal, which lies medial to the anterior clinoid process.
3T AXIAL T2 MR
First of 12 axial T2 MR images presented from inferior to
superior shows the left hypoglossal nerve leaving the
preolivary sulcus of the medulla. The spinal root of the
accessory nerve (CNXI) ascends through the foramen
magnum, lateral to the brainstem, to unite with the cranial
roots of the accessory nerve before exiting via the jugular
foramen.
Glossopharyngeal (CNIX), vagus (CNX), and cranial
(bulbar) roots of spinal accessory (CNXI) nerves emerge
from the lateral brainstem posterior to olive in the
postolivary sulcus and exit the skull base via the jugular
foramen. Do not confuse the posterior or anterior inferior
cerebellar arteries for cranial nerves.
Nucleus of hypoglossal nerve (CNXII) forms a characteristic
bulge on the floor of the 4th ventricle called the hypoglossal
trigone. It is often difficult to separate CNIX from CNX in the
basal cistern.
Abducens (CNVI) nerves exit the brainstem anteriorly at the
pontomedullary junction just above the pyramid, ascending
from there through the prepontine cistern toward the clivus.
Cochlear nerve nuclei are found on the lateral surface of the
inferior cerebellar peduncle (restiform body).
CNVII and CNVIII exit the brainstem laterally at the
pontomedullary junction to enter the cerebellopontine angle
cistern. CNVII lies anterior to CNVIII in the cerebellopontine
angle cistern. Notice CNVI piecing the dura on the patient's
left to enter the Dorello canal, an interdural channel passing
along the dorsal surface of the clivus within the basilar
venous plexus toward the cavernous sinus.
The Meckel cave is formed by a dural reflection, lined with
arachnoid and containing CSF. The Gasserian ganglion
(trigeminal ganglion) is semilunar in shape and lies
anteroinferiorly in the Meckel cave.
CNV exits the lateral pons at a point referred to as the root
entry zone. The preganglionic segment courses anteriorly
through the prepontine cistern and passes over the petrous
apex to enter the Meckel cave via the porus trigeminus
(entrance to Meckel cave).
In this image, the oculomotor nerve (CNIII) can be seen
surrounded by high-signal CSF as it enters the roof of the
cavernous sinus. This area is referred to as the oculomotor
cistern. CNIII travels anterolaterally, becoming incorporated
into the lateral wall of the cavernous sinus near the anterior
clinoid process.
At the level of the upper pons, important vascular
relationships of CNIII passing between the posterior
cerebral and superior cerebellar arteries are visible. Notice
CNIII coursing anteriorly within the suprasellar cistern
adjacent to the posterior communicating artery. An
aneurysm of the posterior communicating artery will result in
compression of CNIII.
Anteriorly, note that the optic nerves (CNII) form the optic
chiasm in the suprasellar cistern. Fibers originating from the
nasal halves of the retina cross within the optic chiasm.
CNIII courses anteriorly within the suprasellar cistern
toward the cavernous sinus.
CNIII is seen on the patient's left, exiting the brainstem
along the medial aspect of the cerebral peduncle, where it
enters the interpeduncular cistern. The trochlear nerve
(CNIV) decussates in the superior medullary velum, then
exits along the dorsal surface of the midbrain below the
inferior colliculus to enter the quadrigeminal plate cistern.
From there, CNIV courses around the brainstem below the
tentorium cerebelli in the ambient cistern passing between
the posterior cerebral and superior cerebellar arteries.
Optic tracts connect the lateral geniculate body to the optic
chiasm. Only a portion of the optic tracts are visible here.
3T CORONAL T2 MR
First of 6 coronal T2 MR images of the brainstem, cisterns,
and cranial nerves, presented from posterior to anterior, is
shown. Preganglionic segment of the trigeminal nerve is
seen arising from the lateral pons. Also seen are the facial
and vestibulocochlear nerves traversing the cerebellopontine
angle cistern into the IAC.
Oculomotor nerves are seen emerging from the medial
aspect of the cerebral peduncle into the interpeduncular
cistern. Basal cistern cranial nerves are not visible. The
abrupt transition between the pons and the medulla is
termed the pontomedullary junction.
In this image, notice the oculomotor nerves passing
between the posterior cerebral artery above and the
superior cerebellar artery below. The distal preganglionic
segment of CNV is poised to enter the porus trigeminus on
its way into the Meckel cave.
This image shows the oculomotor nerve between the
posterior communicating artery above and the superior
cerebellar artery below. The trigeminal nerve is visible
entering the porus trigeminus of the Meckel cave.
Here, the optic tracts are seen converging toward the optic
chiasm. Note a large left anterior choroidal artery coursing
posterolaterally within the suprasellar cistern. Preganglionic
fibers of the trigeminal nerve are seen within the Meckel
cave. The Meckel cave is formed by a reflection of the
dura, which is lined with arachnoid, contains CSF, and
communicates freely with the prepontine cistern.
In this most anterior coronal T2 image, the pituitary is seen
below the optic chiasm. Notice the oculomotor nerve is
entering the cavernous sinus in the oculomotor cistern. The
high-signal ring around CNIII is CSF.
Additional Images
Coronal T1 C+ FS MR through the cavernous sinus shows
the oculomotor nerves (CNII) in the superior margin of the
cavernous sinus lateral wall. The abducens nerve (CNVI)
is the only nerve deep within the cavernous sinus and may
be affected by a cavernous carotid aneurysm. The
mandibular division of the trigeminal nerve (CNV3) is seen
coursing through the foramen ovale.
Coronal STIR MR shows the olfactory bulbs (CNI) along
the floor of the anterior cranial fossa, just above the
cribriform plates. The olfactory bulb and tracts are not true
cranial nerves but extensions of the brain. The optic nerves
(CNII) are also not true cranial nerves but rather
extensions of the brain surrounded by cerebral spinal fluid in
the optic nerve sheath.
Olfactory Nerve (CNI)
Main Text
T ERM INOLOGY
Abbreviations
• Olfactory nerve (CNI)
Synonyms
• 1st cranial nerve
Definitions
• CNI: Visceral afferent cranial nerve for sense of smell
IMAGING ANATOMY
Overview
• Olfactory nerve segments

Receptor neurons in olfactory epithelium in nasal vault
Transethmoidal segment through cribriform plate
Intracranial olfactory bulb, tract, and cortex
Nasal Epithelium
• Pseudostratified columnar epithelium (~ 2 cm²), classically

described in roof of each nasal cavity, adjacent septum, and
lateral nasal cavity wall, including superior turbinates
Recent studies show more extensive distribution up to
middle turbinate, posterior and middle septum
• This epithelium contains b ipolar olfactory receptor cells
Their peripheral processes (or dendrites) act as sensory
receptors for smell, each neuron expressing single type
of odorant receptors out of ~ 400-500 types
• Olfactory glands (of Bowman) secrete mucous, which
solubilizes inhaled scents (odorant molecules)
Transethmoidal Segment
• Hundreds of central processes (or axons) of receptor cells

are bundled into unmyelinated fascicles (fila olfactoria)
interleaved with specialized glial cells called olfactory
ensheathing cells
Fila olfactoria are true olfactory nerves
~ 20 fila traverse cribriform plate on each side of nasal
cavity to synapse with olfactory bulb neurons
Intracranial Olfactory Bulb and Tract
• Olfactory bulb and tracts are extensions of brain, not

nerves, but historically referred to as 1st cranial nerve
• Olfactory bulb (mean volume: 125 ± 17 mm³) is closely
apposed to cribriform plate at ventral surface medial frontal
lobe
Histologically, bulb contains 6 concentric cell layers
Axons within fila from receptor cells expressing same
type of odorant receptor converge to spherical
"glomerulus" in glomerular layer of bulb where they
synapse with processes of secondary neurons (mitral
and tufted cells) in deeper layers of bulb
– Short axon and granule cells modulate secondary
neurons
Axons of mitral and tufted cells coalesce to form lateral
olfactory tract
Recent studies have shown that main olfactory bulb is
one of most prominent sites where intrinsic neurons are
generated continuously after birth and in adulthood
from cells located in subventricular zone of lateral
ventricle
• Olfactory tract (mean length: 28-30 mm) trifurcates to
medial, intermediate, lateral striae at anterior perforated
substance, where intermediate striae terminate
This trifurcation creates olfactory trigone
Anterior perforated substance is perforated by multiple
small vascular structures
Olfactory tract is made up of secondary sensory axons,
not primary sensory axons
Majority of fibers project through lateral olfactory stria
and intermediate stria
Anterior olfactory nucleus formed by some neurons
along olfactory tract
Olfactory tubercle is immediately behind division of
olfactory stria, fused with anterior perforated substance
Intracranial, Central Pathways
• Complex connections, incompletely elucidated in humans

• Olfactory cortex
Cortical areas that receive input from olfactory bulb
Composed of anatomically distinct areas
– Piriform cortex, olfactory tubercle, anterior olfactory
nucleus, anterior cortical nucleus of amygdala and
periamygdaloid cortex, and anterior parts of
entorhinal cortex
• Lateral olfactory striae
Formed by majority of fibers of olfactory tracts
Course over limen of insula to piriform (previously called
prepiriform) cortex anterior to uncus and then to medial
surface of amygdala
– 3-layered piriform cortex is phylogenetically older
than typical 6-layer cortex
– Olfactory system is only sensory modality without
thalamic relays
On way to prepiriform area collaterals are given to
subfrontal or frontal olfactory cortex
Fibers also to subthalamic nuclei with collaterals/terminal
fibers to thalamus and stria medullaris
Projections from piriform cortex go to orbitofrontal
cortex, thalamus (medial dorsal thalamic nucleus),
hypothalamus, amygdala, and hippocampal formation
• Medial olfactory striae
Majority terminate in parolfactory area of Broca (medial
surface in front of subcallosal gyrus), some in subcallosal
gyrus and anterior perforated substance
Few fibers go contralaterally in anterior commissure
• Medial forebrain bundle
Formed by fibers from basal olfactory region,
periamygdaloid area, and septal nuclei
Some fibers terminate in hypothalamic nuclei
Most fibers go to autonomic areas in brainstem (reticular
formation, salivatory nuclei, dorsal vagus nucleus)
In human imaging studies, olfactory tubercle seen
between uncus and medial forebrain bundle

• Olfactory dysfunction imaging depends on clinical context
Sinus CT with coronal reconstructions typically done in
post-URI anosmia, head trauma, or sinus surgery
MR of brain and sinonasal region used with suspected
neurodegenerative disease (Alzheimer, Parkinson),
neurologic symptoms, olfactory hallucinations,
hypogonadism, or lifelong anosmia
Imaging Sweet Spots
• Intracranial: Include anterior cranial fossa floor and medial

temporal lobes
• Extracranial: Include nasal vault and cribriform plate
Imaging Pitfalls
• Coronal sinus CT includes nasal vault and cribriform plate

but insensitive to intracranial pathology
• Remember to include medial temporal lobes in assessment
Clinical Importance
• CNI dysfunction produces unilateral anosmia

• Esthesioneuroblastoma arises from olfactory epithelium
• Olfactory ensheathing cells can give rise to schwannomas
• Head trauma may cause anosmia: Cribriform plate fracture
or shear forces; anterior temporal lobe injury
• Seizures involving olfactory network produce "uncinate fits"
with olfactory hallucinations, variable oroglossal
automatisms, and impaired awareness
• Olfactory bulb volumes decreased in head trauma, chronic
rhinosinusitis, Alzheimer disease, multiple sclerosis,
schizophrenia
Image Gallery
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GRAPHICS
Graphic of olfactory system viewed from below shows

olfactory tracts coursing from olfactory bulbs to the
olfactory trigone. In the olfactory trigone, fibers split up into
lateral, intermediate, and medial striae. The majority of
fibers course through the lateral stria to the piriform area
and amygdala. Some fibers in the medial stria course
through the anterior commissure to connect to the opposite
tract. The majority of intermediate stria fibers terminate in
the anterior perforated substance.
Graphic of olfactory system seen from an anterolateral

oblique perspective shows central processes from bipolar
olfactory cells in the olfactory epithelium crossing the
cribriform plate bundled as fila olfactoria (~ 20 per side) and
connecting with secondary neurons in the olfactory bulbs.
The olfactory trigone is visible dividing into lateral,
intermediate, and medial striae.
CORONAL NECT
First of 3 coronal bone CTs through the anterior cranial

fossa are presented from posterior to anterior. The
olfactory epithelium is found on the roof of the nasal cavity,
extending inferolaterally on the superior turbinate and
inferomedially on the nasal septum. The olfactory nerves
pass through perforations in the cribriform plate. The
olfactory bulbs sit just above the cribriform plates.
In this CT image, the ethmoid bone forms the medial floor of
the anterior cranial fossa and consists of the cribriform plate
and crista galli. The fenestrated cribriform plate is
depressed relative to the orbital plate of the frontal bone.
The fovea ethmoidalis, roof of the ethmoid, is the most
medial portion of the orbital plate of the frontal bone and
separates the ethmoid labyrinth from the anterior cranial
fossa.
The anterior cribriform plate is seen at the base of the
larger anterior crista galli.
3T CORONAL T2 MR
posterior to anterior shows the triangular olfactory tracts,
which are composed of centrally projecting axons,
embedded within the olfactory sulcus.
The olfactory sulcus is easily identified separating the gyrus
rectus medially from the orbital gyrus laterally. Again note
the olfactory tracts at the base of the olfactory sulcus.
In this image through the anterior cribriform plate, note the
olfactory bulbs. The olfactory bulbs are rostral enlargement
of the olfactory tracts, which lie on either side of the midline
on the intracranial surface of the cribriform plate. The
olfactory nerves arise from the olfactory epithelium located
in the roof nasal cavity and pass through the fenestrated
cribriform plate to end in the olfactory bulbs.
3T CORONAL T1 MR AND SAGITTAL CT

Coronal T1 MR shows the olfactory bulbs, which are
isointense to brain, located just above the cribriform plate.
The olfactory epithelium is located in the upper nasal cavity.
The olfactory bulb and tracts are extensions of the brain
and not a true cranial nerve.
Coronal T1 MR at the level of the crista galli, formed by the
ethmoid bone, is shown. Note the normal T1-hyperintense
signal within the crista galli related to normal marrow fat.
The falx cerebri attaches to the posterior aspect of the
crista galli. The anterior cribriform plate is located at the
base of the larger anterior crista galli.
Sagittal bone CT shows the floor of the anterior cranial
fossa primarily formed by the cribriform plate, orbital plate
of the frontal bone, ethmoid sinus roof, and planum
sphenoidale. Note the foramen cecum at the midline,
anterior to the crista galli.
CLINICAL CORRELATION
Sagittal T1 MR shows an isointense mass in the olfactory
groove along the posterior margin of the crista galli in a
patient with unilateral anosmia.
Axial CT in the same patient shows smooth bone
remodeling, typical of benign schwannoma. The majority of
nerve sheath tumors of the head and neck present as
expansile round or oval soft tissue masses with adjacent
bone remodeling. Marked enhancement is typical.
Coronal T1 C+ MR shows an avidly enhancing
esthesioneuroblastoma with involvement of the nasal cavity
and extension into the anterior cranial fossa and bilateral
orbits. Avid enhancement is characteristic of this highly
vascular neoplasm. These tumors typically arise from the
olfactory epithelium in the superior nasal cavity at the
cribriform plate. Cysts may be present along the intracranial
tumor margins.
Additional Images
posterior to anterior shows the triangular olfactory tracts,
which are composed of centrally projecting axons,
embedded within the olfactory sulcus.
The olfactory sulcus is easily identified separating the gyrus
rectus medially from the orbital gyrus laterally. Again note
the olfactory tracts at the base of the olfactory sulcus.
In this image through the anterior cribriform plate, note the
olfactory bulbs. The olfactory bulbs are rostral enlargement
of the olfactory tracts, which lie on either side of the midline
on the intracranial surface of the cribriform plate. The
olfactory nerves arise from the olfactory epithelium located
in the roof nasal cavity and pass through the fenestrated
cribriform plate to end in the olfactory bulbs.
Optic Nerve (CNII)
Main Text
T ERM INOLOGY
Abbreviations
• Optic nerve (CNII)
Synonyms
• 2nd cranial nerve
Definitions
• CNII: Nerve of sight

• Visual pathway consists of optic nerve, optic chiasm, and
retrochiasmal structures
IMAGING ANATOMY
Overview
• Optic nerve not true cranial nerve but rather extension of

brain
Represents collection of retinal ganglion cell axons
Myelinated by oligodendrocytes not by Schwann cells as
with true cranial nerves
Enclosed by meninges
Throughout its course to visual cortex, nerve fibers are
arranged in retinotopic order
• Optic nerve has 4 segments
Intraocular, intraorbital, intracanalicular, and
intracranial
• Partial decussation CNII fibers within optic chiasm
Axons from medial portion of each retina cross to join
those from lateral portion of opposite retina
• Retrochiasmal structures: Optic tract, lateral geniculate
body, optic radiation, and visual cortex
Optic Pathway
• Optic nerve: Intraocular segment

1 mm in length
Region of sclera termed lamina cribrosa where ganglion
cell axons exit globe
• Optic nerve: Intraorbital segment
20-30 mm in length
Extends posteromedially from back of globe to orbital
apex within intraconal space of orbit
CNII longer than actual distance from optic chiasm to
globe allowing for movements of eye
Covered by same 3 meningeal layers as brain
– Outer dura, middle arachnoid, and inner pia
– Subarachnoid space (SAS) between arachnoid and
pia contains cerebrospinal fluid (CSF); continuous
with SAS of suprasellar cistern
– Fluctuations in intracranial pressure transmitted via
SAS of optic nerve-sheath complex
Central retinal artery
– 1st branch of ophthalmic artery
– Enters optic nerve ~ 1 cm posterior to globe with
accompanying vein to run to retina
• Optic nerve: Intracanalicular s egment
4- to 9-mm segment within bony optic canal
Ophthalmic artery lies inferior to CNII
Dura of CNII fuses with orbit periosteum (periorbita)
• Optic nerve: Intracranial segment
~ 10 mm in length from optic canal to chiasm
Covered by pia and surrounded by CSF within
suprasellar cistern
Ophthalmic artery runs inferolateral to nerve
• Optic chiasm
Horizontally oriented; X-shaped structure within
suprasellar cistern
Forms part of floor of 3rd ventricle between optic recess
anteriorly and infundibular recess posteriorly
Immediately anterior to infundibulum (pituitary stalk),
superior to diaphragma sellae
Anteriorly chiasm divides into optic nerves
In chiasm nerve, fibers from medial 1/2 of retina cross to
opposite side
Posteriorly, chiasm divides into optic tracts
Medial fibers of optic tracts cross in chiasm to connect
lateral geniculate bodies of both sides (commissure of
Gudden)
• Optic tracts
Posterior extension of optic chiasm
Fibers pass posterolaterally, curving around cerebral
peduncle and divide into medial and lateral bands
– Lateral band (majority of fibers) ends in lateral
geniculate body of thalamus
– Medial band goes by medial geniculate body to
pretectal nuclei deep to superior colliculi
• Optic radiation and visual cortex
Axons from lateral geniculate body form optic radiations
(geniculocalcarine tracts)
Fan out from lateral geniculate body and run as broad
fiber tract to calcarine fissure
– Initially pass laterally behind posterior limb internal
capsule and basal ganglia
– Extend posteriorly around lateral ventricle passing
through posterior temporal and parietal lobes
– Terminate in calcarine cortex (primary visual cortex)
on medial surface of occipital lobes

• CT best for skull base and optic canal bony anatomy

• MR for CNII, optic chiasm, and retrochiasmal structures
Axial and coronal thin-section T2, T1, and T1 C+
Imaging Pitfalls
• Orbital CT may see subtle calcified optic sheath meningioma

when MR may not
Clinical Importance
• Lesion location
Optic nerve pathology: Monocular visual loss
Optic chiasm pathology: Bitemporal heteronymous
hemianopsia (loss of bilateral temporal visual fields)
Retrochiasmal pathology: Homonymous hemianopsia
(vision loss in contralateral visual field)
• Increased intracranial pressure transmitted along SAS of
optic nerve-sheath complex
Manifests clinically as papilledema
Imaging shows flattening of posterior sclera, tortuosity
and elongation of intraorbital optic nerves, and
dilatation of perioptic SAS
Image Gallery
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GRAPHICS
Axial graphic through the visual pathway shows medial

retinal fibers crossing in the optic chiasm so that fibers from
left 1/2 of both retinas course in left optic tract, and fibers in
right 1/2 of both retinas course in right optic tract (purple
and green, respectively). Majority of retinal nerve fibers
terminate in lateral geniculate bodies, where synaptic
neuronal cell bodies give rise to optic radiations, which
extend to visual cortices. A few retinal nerve fibers (blue)
involved in optic reflexes bypass lateral geniculate bodies
and terminate in pretectal nuclei. Medial fibers of optic
tracts cross in chiasm to connect lateral geniculate bodies
of both sides (yellow).
Axial graphic of the orbit shows the 4 segments of the optic
nerve (intraocular, intraorbital, intracanalicular, and
intracranial). At the annulus of Zinn, the dural sheath of the
intraorbital segment becomes contiguous with periorbita.
Sagittal graphic through the orbit shows continuity of the

dural sheath of the intraorbital segment of CNII with the
sclera. At the annulus of Zinn, the dural sheath is continuous
with the periorbita (not seen in this graphic). Central retinal
artery and vein enter the distal intraorbital segment of CNII
to supply the retina.
Coronal graphic through the distal optic nerve shows
encasement of the optic nerve by the arachnoid and dura.
Subarachnoid space of CNII is continuous with the cerebral
subarachnoid space. Central retinal artery and vein pierce
the dura of the distal intraorbital segment and continue to
the retina in the center of CNII.
3T AXIAL STIR MR
First of 3 axial STIR MR images from inferior to superior
demonstrates intraorbital, intracanalicular, and intracranial
segments of the optic nerve. Intraorbital segment extends
from the back of the globe posteromedially to the orbital
apex within the intraconal space. Intracanalicular segment
passes through the bony optic canal. Intracranial segment is
~ 10 mm long from the optic canal to the chiasm.
Subarachnoid space with cerebrospinal fluid surrounds the
optic nerve and is continuous with the subarachnoid space
of the suprasellar cistern. Optic chiasm lies within the
suprasellar cistern. Optic tracts extend posteriorly around
the cerebral peduncles to the lateral geniculate body.
Majority of fibers from optic tracts terminate in the lateral
geniculate body located at the posteroinferior aspect of the
thalamus. Efferent axons from the lateral geniculate body
form optic radiation extending to the calcarine cortex.
3T CORONAL T1 MR
First of 3 coronal T1 MR images through the orbit from
posterior to anterior is shown. Section through the orbital
apex shows the optic nerve passing through the common
annular tendon, which serves as the site of origin of the
rectus muscles.
In this image, both the superolateral ophthalmic vein and the
superomedial ophthalmic artery are visible. Note that the
subarachnoid space is visible as a thin, black line
surrounding the optic nerve, a finding often not seen on
routine T1 imaging of the orbit.
In this image just behind the globe, all the extraocular
muscles are clearly visible. Notice the levator palpebrae
superioris muscle may be difficult to distinguish from the
superior rectus muscle even with high-resolution MR
imaging.
3T CORONAL T2 MR
First of 6 coronal T2 MR images shows the optic tracts and
chiasm from posterior to anterior. The optic tracts course
posterolaterally, curving around the cerebral peduncle to
eventually terminate in the lateral geniculate body (lateral
root) and pretectal nuclei at the superior colliculi (medial
band).
Optic tracts course through the posterior suprasellar cistern
toward the ambient cistern, closely related to the basal vein
(of Rosenthal).
In this image through the back of the optic chiasm, the optic
tracts are shown as the posterior extension of the optic
chiasm carrying fibers from the ipsilateral 1/2 of both
retinae. The tuber cinereum leads to the infundibulum
(pituitary stalk). Notice the 3rd ventricle just above the
posterior optic chiasm.
In this image, the optic chiasm is seen forming part of the
floor of the 3rd ventricle between the optic recess anteriorly
and the infundibular recess posteriorly. It is immediately
anterior to the infundibulum (pituitary stalk).
Optic chiasm is a horizontally oriented, X-shaped structure
within the suprasellar cistern. Nerve fibers from the medial
halves of both retinae cross to continue to the lateral
geniculate bodies. Interruption of crossing chiasmatic fibers
leads to bitemporal hemianopia.
The intracranial segment of the optic nerves are visible in
this image. This segment is ~ 10 mm in length from the
optic canal anteriorly to the optic chiasm posteriorly. The
nerves are covered by pia at this point. The bright CSF
within the suprasellar cistern surrounds the nerves.
3T AXIAL AND SAGITTAL T1 MR

Axial T1 MR demonstrates the intraorbital segment of the
optic nerve extending posteromedially from the back of the
globe to the orbital apex, surrounded by fat within the
intraconal space. Note the intracanalicular segment passing
through the bony optic canal.
Axial T1 MR shows the origin of the optic nerve from the
globe. Nerve fibers of the retina unite, forming the optic
nerve before exiting the eyeball through the lamina cribrosa,
a thin, perforated portion of the sclera. In the superior orbit,
the lacrimal gland is seen in its superolateral fossa.
Sagittal T1 MR through the optic nerve demonstrates the
intraorbital segment of the optic nerve. Sclera of the globe
is hypointense, while the pigmented choroid of the uvea is
hyperintense due to T1-shortening effects of melanin.
3T MP2RAGE MR
First of 3 sections from a magnetization prepared 2 rapid
acquisition gradient echoes (MP2RAGE) MR dataset is
shown. This axial slice shows the optic nerve as it leaves
the eye and the optic chiasm.
Second in the series is a sagittal slice of an MP2RAGE MR
showing the optic chiasm.
Third in the series showing a coronal slice of an MP2RAGE
MR shows the optic nerve.
3T DIFFUSION TRACTOGRAPHY
The first of 3 views of a diffusion MR tractography
reconstruction of the visual pathway is shown on the
superior side. The background shows an axial MP2RAGE
MR slice and 3D models of the thalamus. The 4 segments
of the optic nerve are shown, where the portions mapping
the right visual field are shown in yellow and pink, while the
segments mapping the left visual field are shown in purple
and green. The complete pathway is shown, from the eye,
through the optic chiasm, and to the lateral geniculate
nucleus of the thalamus to visual cortex in the occipital lobe.
The 2nd view in the series shows a detailed view of the
optic chiasm, which includes a crossing of nerve segments
from the left and right visual hemifields.
A 3rd view in the series shows the inferior view of the visual
pathway.
Oculomotor Nerve (CNIII)
Main Text
T ERM INOLOGY
Abbreviations
• Oculomotor nerve (CNIII)

• Oculomotor nuclear complex (ONC)
Synonyms
• 3rd cranial nerve
Definitions
• CNIII: Motor nerve to extraocular muscles (EOMs) except

lateral rectus (CNVI) and superior oblique muscles (CNIV);
parasympathetic motor to pupillary sphincter and ciliary
muscle
IMAGING ANATOMY
Overview
• Both motor cranial nerve with general somatic efferent

fibers as well as general visceral efferent fibers
(parasympathetic)
• Supplies all EOMs except superior oblique and lateral rectus
muscles via general somatic efferent innervation
• Innervates pupillary sphincter and ciliary muscles via
parasympathetic innervation
• Nerve originates from ONC in posterior midbrain
• Nerve can be divided into 7 segments: Intramesencephalic,
interpeduncular cisternal, petroclinoid, trigonal, cavernous,
fissural, and orbital
Oculomotor Nuclear Complex
• Paired paramedian ONCs are located in posterior aspect of

midbrain at level of superior colliculus
• Partially embedded in periaqueductal gray matter anterior
(ventral) to cerebral aqueduct
• ONC has complex cytoarchitecture with multiple motor
nuclei and parasympathetic nucleus
• Contains motor neurons of medial, inferior, and superior
recti, inferior oblique, and levator palpebrae muscles
• Motor neurons are arranged into subgroups generally
referred to as nuclei
• Motor nuclei are arranged in 2 paramedian clusters or
stacks referred to as columns or somatic columns
• Each paramedian somatic column consists of 4 relatively
distinct nuclei, providing axons to EOMs
Ventral nucleus : Ipsilateral medial rectus
Central nucleus : Contralateral superior rectus and
ipsilateral inferior oblique
Dorsolateral nucleus : Ipsilateral medial rectus
Dorsomedial nuclei : Ipsilateral inferior rectus
• Just inferior to paired columns is single midline motor
nucleus, central caudal nucleus
Contains motor neurons for levator palpebrae muscle,
possibly provides crossed and uncrossed axons
• Edinger-Westphal nucleus ( EWn)
More complex than classically considered
– Anatomy is confounded by differences in primates
and humans
– Nomenclature confusing given inconsistent
application of term EWn to 2 different groups of
neurons that contain different cell types and provide
different function
1st group: Preganglionic parasympathetic
component (EWpg)
2nd group: Nonpreganglionic centrally
projecting component (EWcp)
Edinger-Westphal nucleus, parasympathetic ( EWnp)
– Provides parasympathetic motor to pupillary
sphincter and ciliary muscles of eye
– In humans, preganglionic parasympathetic neurons
are located posteromedial to somatic columns near
midline but do not form compact or distinct nucleus
Edinger-Westphal nucleus, centrally projecting (
EWncp)
– Located posteromedial to somatic columns, in
between columns and parasympathetic neurons of
EWpg
– Forms compact and distinct nucleus
– Consists of peptidergic neurons that project to
brainstem, spinal cord, and prosencephalic regions
– Not definitely related to ocular function; may
function in feeding behavior, stress responses,
addiction, and pain
• Nucleus of Perlia
Small linear nucleus medial to main motor nuclei near
midline of midbrain
Function less clear; may function in ocular convergence
May provide some motor fibers to superior rectus
• Arterial supply to ONC and intramesencephalic nerves is
via group of small penetrating arteries that arise from
terminal regions of basilar artery near origins of superior
cerebellar and posterior cerebral arteries
Intramesencephalic Segment
• Intraaxial segment resides within midbrain and extends

from ONC to interpeduncular cistern
• CNIII fascicles course anteriorly at least partially through
medial longitudinal fasciculus (MLF), red nucleus,
substantia nigra, and medial cerebral peduncle
• Oculomotor nerve fascicles converge in posterior-to-anterior
direction
• Exit midbrain into interpeduncular cistern
Interpeduncular Cisternal Segment
• CNIII leaves midbrain medially to cerebral peduncle in

lateral part of interpeduncular fossa
• Nerve may arise as tiny rootlets that immediately unite and
extend as single root
• Cisternal segment extends from exit point along medial side
of cerebral peduncle through interpeduncular and
prepontine cisterns to posterior petroclinoid fold, posterior
margin of oculomotor triangle
• Passes between posterior cerebral artery (PCA) above and
superior cerebellar artery (SCA) below
• Courses inferior to posterior communicating artery (PCOM)
and medial to free edge of tentorium cerebelli
• Measures ~ 2.1 mm in diameter within cistern
• Topographically, pupillary fibers are superficially located in
cisternal portion of CNIII
Petroclinoid Segment
• Located between cisternal and trigonal segments
• Defined posteriorly by posterior petroclinoid fold and
anteriorly by oculomotor porus (opening) of roof of
cavernous sinus
• Oculomotor triangle represents floor of petroclinoid segment
Trigonal Segment
• Petroclinoid segment ends at oculomotor porus where nerve

pierces roof of cavernous sinus, near center of oculomotor
triangle
• Oculomotor cistern, CSF-filled arachnoid and dural cuff,
begins at oculomotor porus and extends ~ 6 mm
• Trigonal segment of oculomotor nerve travels within
oculomotor cistern as it enters superolateral cavernous
sinus roof
• Trigonal segment terminates when nerve is incorporated
into fibrous lateral wall of cavernous sinus
• Cistern and trigonal segment is recognized surgically as
avascular space used to mobilize nerve during cavernous
sinus surgery
Cavernous Segment
• Incorporated into lateral dural wall of cavernous sinus just

under tip of anterior clinoid process
• This wall consists of 2 layers
Superficial, dense, and formed from dura
Deep endosteal layer that invests nerves running in
lateral wall
• Cavernous segment of CNIII extends just past anterior
clinoid process where superior orbital fissure (SOF) begins
• Carotid-oculomotor membrane
Layer of dura that lines lower margin of anterior clinoid
process, extends medially to form proximal dural ring
Separates lower margin of anterior clinoid process from
cavernous segment CNIII and extends medially around
carotid artery
• CNIII remains most cephalad of all cranial nerves within
cavernous sinus
• CNIII superolateral to cavernous internal carotid artery
• This segment is ~ 14 mm in length
Fissural Segment
• CNIII courses along lateral margin of optic strut as it passes

through medial part of SOF
• Fissural segment of oculomotor nerve splits into its superior
and inferior divisions
• ~ 6 mm long
• Fissural segment extends from anterior clinoid process to
oculomotor foramen of SOF
Orbital Segment
• Superior and inferior branches of CNIII enter orbit through

SOF and pass through annulus tendineus (annulus of Zinn)
• Annulus of Zinn partially segments SOF into lateral
component and medial component; medial component is
referred to as oculomotor foramen
• Superior branch supplies levator palpebrae superioris and
superior rectus muscles
• Inferior branch supplies inferior rectus, medial rectus, and
inferior oblique muscles
• Preganglionic parasympathetic fibers follow inferior branch
to ciliary ganglion of orbit
Postganglionic parasympathetic fibers continue as short
ciliary nerves to enter globe with optic nerve
In globe, short ciliary nerves reach ciliary body and iris
Control papillary sphincter function and accommodation
via ciliary muscle

• Bone CT best for skull base, bony foramina

• MR for intraaxial, cisternal, cavernous segments
Thin-section, high-resolution T2 MR sequences in axial
and coronal planes
– Depicts cisternal CNIII surrounded by CSF with high
contrast and high spatial resolution
Postcontrast, fat-saturated T1 MR sequences in axial and
coronal planes
Imaging Sweet Spots
• CNIII nuclear complex and intraaxial segment not directly

visualized
Find periaqueductal gray matter to localize
• Identification of distal basilar artery and branches can be
reliable landmark for finding cisternal CNIII
CNIII passes between PCA above and SCA below
Imaging Pitfalls
• Negative MR and MRA does not completely exclude PCOM

aneurysm
CTA or conventional angiography recommended to
exclude this diagnosis
Clinical Importance
• During trauma, downward shift of brainstem upon impact

can stretch CNIII over petroclinoid ligament
• Uncal herniation pushes CNIII on petroclinoid ligament
• CNIII susceptible to compression by PCOM, PCA, and SCA
aneurysms
• CNIII neuropathy divided into simple if isolated and
complex if with other cranial nerve involvement (CNIV and
CNVI)
Simple CNIII with pupillary involvement
– Must exclude PCOM aneurysm as cause
– Explanation: Parasympathetic fibers are peripherally
distributed
Simple CNIII with pupillary sparing
– Presumed microvascular infarction involves vessels
supplying core of nerve with relative sparing of
peripheral pupillary fibers
• Common etiologies for CNIII dysfunction include
Ischemia (primarily microvascular) in ~ 25% of all cases
Trauma, typically severe, related to herniation
Aneurysms: PCOM > PCA, SCA
Neoplasm, primary or secondary
Multiple sclerosis in young adults
• Less common etiologies include meningioma, pituitary
tumors/apoplexy, schwannoma, vasculitis, meningitis,
neurosarcoid
Image Gallery
Print Images
GRAPHICS
Sagittal graphic shows the oculomotor nerve (CNIII) exiting
from the anterior brainstem. After passing medially to the
trochlear nerve (CNIV) between the superior cerebellar
artery and posterior cerebral artery, it enters the cavernous
sinus. CNIII is the most superior nerve coursing through the
cavernous sinus. Once in orbit, it divides into the superior
and inferior divisions. Preganglionic parasympathetic fibers
travel with the inferior division to join the ciliary ganglion.
Axial graphic clearly depicts CNIII originating from the
oculomotor nuclei complex to travel through the medial
aspect of the red nucleus and substantia nigra before
exiting into the prepontine cistern. After traversing the
cavernous sinus, surrounded by the CSF-filled oculomotor
cistern, it enters the orbit through the superior orbital
fissure, dividing into superior and inferior branches and
passing through the annulus tendineus (annulus of Zinn).
3T AXIAL T2 MR
superior demonstrates the oculomotor nerves entering the
oculomotor cisterns in the posterior roof of the cavernous
sinus. Notice the nerves are surrounded by high-signal CSF.
From here, the oculomotor nerves course anteriorly in the
lateral wall of the cavernous sinus above the trochlear nerve
(CNIV) and enters orbit via the superior orbital fissure.
Oculomotor nerves course anteriorly through the prepontine
cistern inferolateral to the posterior communicating artery
and medial to the uncus of the temporal lobe. The left
oculomotor nerve is seen passing below the posterior
cerebral artery.
After exiting the brainstem, the oculomotor nerves course
anteriorly through the interpeduncular and prepontine
cisterns toward the cavernous sinus, passing between the
posterior cerebral and superior cerebellar arteries.
3T AXIAL T2 AND T1 MR
Axial T2 MR shows both oculomotor nerves coursing
through the interpeduncular cistern.
Oculomotor nerves exit the midbrain from the medial
surface of the cerebral peduncle to enter the
interpeduncular cistern and continue anteriorly underneath
the posterior cerebral arteries.
Axial inversion recovery prepared T1-weighted MR through
the brainstem at the level of superior colliculus is shown.
The paired oculomotor nuclear complex is not directly
visualized. However, since it is partially embedded in
periaqueductal gray matter anterior to the cerebral
aqueduct at the level of the superior colliculus, its position
can be inferred by these landmarks. The approximate
location of the oculomotor nucleus in marked on the left.
3T CORONAL T2 MR
to anterior reveals the most proximal aspects of both
oculomotor nerves exiting the midbrain from the medial
surface of the cerebral peduncle to enter the
interpeduncular cistern.
Oculomotor nerves often emerge from the midbrain by
several rootlets, as seen in this T2 coronal image (circle),
which subsequently fuse to form a single trunk.
Oculomotor nerves pass between the posterior cerebral
artery above and the superior cerebellar artery below. The
proximity of the oculomotor nerve to the uncus makes the
nerve vulnerable to injury through uncal herniation. Its
nearness to the posterior communicating, posterior
cerebral, and superior cerebellar arteries makes it easily
injured by an aneurysm, most commonly by a posterior
communicating aneurysm.
Oculomotor nerves are seen coursing through the
interpeduncular cistern toward the cavernous sinus closely
related to the posterior communicating artery. An aneurysm
of the posterior communicating artery can result in
compression of the oculomotor nerve. The lateral margin of
the Liliequist membrane attaches to the arachnoidal sheath
surrounding oculomotor nerves.
The oculomotor nerve crosses the petroclinoid ligament and
is situated medial to and slightly beneath the level of the
free edge of the tentorium at the point of entry into the roof
of the cavernous sinus.
A short length of the oculomotor nerve is surrounded by a
dural and arachnoid cuff to create the oculomotor cistern
within the roof and lateral wall of the cavernous sinus. The
oculomotor nerve courses anteriorly above the trochlear
nerve within the lateral wall of the cavernous sinus and
enters the orbit via the superior orbital fissure.
CLINICAL CORRELATION
CTA with 3D reformation in a patient with new 3rd nerve
palsy shows bilateral posterior communicating artery origin
aneurysms. Posterior communicating artery origin
aneurysms classically cause 3rd nerve palsy with
associated pupillary dysfunction. It is the most common
aneurysm to result in a 3rd nerve palsy.
This 64-year-old man with a history of squamous cell
carcinoma of the left forehead developed progressive
disease of the orbit and perineural tumor spread to the
superior orbital fissure and cavernous sinus. This axial
contrast-enhanced image though the level of the
interpeduncular cistern demonstrates abnormal thickening
and enhancement of the cisternal CNIII as the tumor
extends in retrograde fashion along the nerve from the
cavernous sinus.
Axial contrast-enhanced MR in a patient with acute
lymphocytic leukemia shows leukemic infiltration of several
cranial nerves, including bilateral CNIII. The nerves show
enlargement and abnormal enhancement of the cisternal
portions, left worse than right. Notice the proximal posterior
cerebral arteries pass medial to the cisternal CNIII and then
pass over the nerves en route to the occipital lobes.
Additional Images
Coronal T1 C+ FS MR in patient with chronic calcified lesion
in the left cavernous sinus (presumed to be meningioma)
demonstrates chronic atrophy of the extraocular muscles on
the left, secondary to oculomotor denervation. Notice there
is preservation of the superior oblique muscle (CNIV) and
the lateral rectus muscle (CNVI) . Optic nerves are
shown.
Coronal CECT in patient with chronic calcified lesion in the
left cavernous sinus (presumed to be meningioma)
demonstrates chronic atrophy of the extraocular muscles on
the left, secondary to CNIII denervation. Notice there is
preservation of the superior oblique muscle (CNIV) and
the lateral rectus muscle (CNVI) . Optic nerves are
shown.
Axial diffusion-weighted image in patient with acute onset of
isolated right 3rd nerve palsy demonstrates 2 tiny foci of
diffusion restriction. The more posterior lesion is near the
expected location of the motor nuclei of the oculomotor
nerve . The more anterior focus likely involves the
intramesencephalic fibers of the oculomotor nerve just prior
to exiting the midbrain at the interpeduncular cistern .
Patient with lymphoma and multiple cranial neuropathies,
including 3rd nerve palsies, shows abnormal enhancement
along both cisternal portions of CNIII .
Coronal T1 C+ FS MR in the same patient shows the
enhancing 3rd nerves bilaterally .
Trochlear Nerve (CNIV)
Main Text
T ERM INOLOGY
Abbreviations
• Trochlear nerve (CNIV)
Synonyms
• 4th cranial nerve
Definitions
• CNIV: Motor nerve to superior oblique muscle
IMAGING ANATOMY
Overview
• CNIV is pure motor nerve (general somatic efferent) that

innervates superior oblique muscle
• Segments: Intraaxial, cisternal, tentorial, cavernous, and
extracranial
Trochlear Nuclei
• Paired nuclei located in paramedian midbrain, ventral to

cerebral aqueduct, and immediately dorsal to medial
longitudinal fasciculus
• Caudal to oculomotor nuclear complex at level of inferior
colliculus
Intramesencephalic Segment
• Trochlear nerve fascicles course posteriorly and inferiorly

around cerebral aqueduct
Fibers then cross (decussate) within superior medullary
velum
Key concept : Each superior oblique muscle is innervated
by ipsilateral CNIV that originates in contralateral
trochlear nucleus
• CNIV exits dorsal midbrain just inferior to inferior colliculus
( only cranial nerve to exit dorsal brainstem)
Cisternal Segment
• CNIV courses anterolaterally in through quadrigeminal and

ambient cisterns
• Surrounded by CSF in subarachnoid space
• In ambient cistern, passes between posterior cerebral artery
above and superior cerebellar artery below, just inferolateral
to CNIII
Tentorial Segment
• CNIV passes anteriorly into groove along lower surface of

free edge of tentorium
• From groove, CNIV pierces dura near posterior margin of
oculomotor triangle, along rostrolateral free edge of
tentorium
• This segment extends from entrance of CNIV into tentorial
groove to anterior petroclinoid fold where nerve enters
cavernous sinus
Cavernous Segment
• CNIV enters roof of cavernous sinus in posterolateral apex

of oculomotor triangle
• CNIV courses in lateral wall inferior to CNIII, superior to
CNV1
Extracranial Segment
• CNIV enters orbit through superior orbital fissure together

with CNIII and CNVI
• Crosses over CNIII and courses medially
• Passes above annulus of Zinn (CNIII and CNVI go through
annulus)
• Supplies motor innervation to superior oblique muscle

• CT best for skull base, bony foramina

• High-resolution MR best for brainstem, cisternal, cavernous,
and intraorbital imaging
• Intraorbital segment not visualized by any imaging modality
or sequence
Imaging Sweet Spots
• CNIV nucleus and intraaxial segment not directly visualized

Nuclei position inferred by identifying periaqueductal
gray matter and cerebral aqueduct at level of inferior
colliculi on high-resolution MR
• MR for intraaxial, cisternal, and cavernous segments
Thin-section, high-resolution T2 and T1 C+ MR in axial
and coronal planes
– Coronal imaging margins: 4th ventricle to anterior
globe; axial imaging margins: Orbital roof-
diencephalon to maxillary sinus roof-medulla
Imaging Pitfalls
• Difficult to visualize normal CNIV despite best MR imaging

efforts
• During image interrogation by radiologist, view known
landmarks along its course
Midbrain → tentorial margin → cavernous sinus →
superior orbital fissure → extraconal orbit
Normal Measurements
• CNIV is smallest cranial nerve (0.75-1.0 mm)

• CNIV has longest intracranial course (~ 7.5 cm)
Clinical Importance
• CNIV neuropathy divided into simple and complex

Simple CNIV neuropathy (isolated)
– Most common form; usually secondary to trauma
– Cisternal segment injury by free edge of tentorium
cerebelli or from posterior cerebral or superior
cerebellar artery aneurysm
– Contusion of superior medullary velum
Complex CNIV neuropathy (associated with other
cranial nerve injury, CNIII ± CNVI)
– Brainstem stoke or tumor
– Cavernous sinus thrombosis, tumor
– Orbital tumor
Clinical Findings
• Paralysis of superior oblique muscle results in extorsion

(outward rotation) of affected eye
• Extorsion is secondary to unopposed action of inferior
oblique muscle
• Patient complaints: Diplopia, weakness of downward gaze,
neck pain from head tilting
• Physical exam: Compensatory head tilt usually away from
affected side
Image Gallery
Print Images
GRAPHICS
Sagittal graphic shows that the trochlear nucleus gives rise
to fibers that form the contralateral trochlear nerve. After
exiting the dorsal brainstem, CNIV courses lateral to the
oculomotor nerve between the posterior cerebral artery and
superior cerebellar artery. After its long cisternal course,
CNIV enters the cavernous sinus and runs inferolateral to
CNIII and superior to the ophthalmic division of trigeminal
nerve (CNV1).
Axial graphic shows the trochlear nerves originating from
the trochlear nuclei and decussating in the superior
medullary velum. CNIV runs lateral to the oculomotor nerve
between the posterior cerebral artery and superior
cerebellar artery and continues inferolateral with CNIII
through the cavernous sinus. It crosses over CNIII to enter
orbit above the annulus of Zinn, then courses medially over
the levator palpebrae muscle to innervate the superior
oblique muscle.
3T AXIAL T2 MR
superior through the midbrain is shown. The left trochlear
nerve passes around the brainstem within the ambient
cistern, where it courses anteriorly below the tentorium
cerebelli. The trochlear nerves decussate in the superior
medullary velum with fibers from the nucleus passing to the
contralateral CNIV.
Trochlear nerve (CNIV) is the smallest cranial nerve (0.75-
1.00 mm in diameter) and is not routinely visualized. In
addition, the trochlear nerve may easily be confused with
numerous small arteries and veins in the ambient cistern.
After decussating in the superior medullary velum, the
trochlear nerve exits the dorsal surface of the brainstem
below the inferior colliculus to enter the quadrigeminal plate
cistern. The trochlear nerve is the only cranial nerve to exit
the dorsal brainstem.
3T CORONAL T2 MR
First of 3 coronal T2 MR images from posterior to anterior
through the brainstem demonstrates the right trochlear
nerve exiting from the dorsal brainstem below the inferior
colliculus as multiple discrete rootlets enter the
quadrigeminal plate cistern. The left trochlear nerve is
obscured by the lateral mesencephalic vein.
Trochlear nerves can be visualized bilaterally coursing
anteriorly within the ambient cistern below the free margin
of the tentorium cerebelli. Only very focused thin-section
high-resolution T2 MR imaging has any chance of seeing
CNIV in this location.
At the level of the basilar artery, the trochlear nerve is
hidden on the left but visible on the right, inferolateral to the
oculomotor nerve. Both nerves pass between the posterior
cerebral artery and the superior cerebellar artery.
3T CISS MR
Axial section through a constructive interference in steady-
state (CISS) MR shows the trochlear nerve alongside the
brainstem and temporal lobe.
Axial section through a constructive interference in steady-
state (CISS) MR shows the trochlear nerve alongside the
3T T2-SPACE MR
Axial section through a T2 sampling perfection with
application-optimized contrasts using flip angle evolution
(SPACE) MR shows the trochlear nerve alongside the
Coronal section through a T2 sampling perfection with
application-optimized contrasts using flip angle evolution
(SPACE) MR shows the trochlear nerve alongside the
Trigeminal Nerve (CNV)
Main Text
T ERM INOLOGY
Abbreviations
• Trigeminal nerve (CNV)

• Ophthalmic division, trigeminal nerve (CNV1)
• Maxillary division, trigeminal nerve (CNV2)
• Mandibular division, trigeminal nerve (CNV3)
Definitions
• CNV: Great sensory cranial nerve of head and face; motor

nerve for muscles of mastication
IMAGING ANATOMY
Overview
• Mixed nerve (both sensory, motor components)

• 4 segments: Intraaxial, cisternal, interdural, and extracranial
Intraaxial Segment
• 4 nuclei (3 sensory, 1 motor) in brainstem, upper cord

Mesencephalic nucleus CNV
– Slender column of cells projecting cephalad from
pons to level of inferior colliculus
– Found anterior to upper 4th ventricle/aqueduct near
lateral margin of central gray
– Afferent fibers for facial proprioception [teeth, hard
palate, and temporomandibular joint (TMJ)]
– Sickle-shaped mesencephalic tract descends to
motor nucleus, conveys impulses that control
mastication and bite force
Main sensory nucleus CNV
– Nucleus lies lateral to entering trigeminal root
– Provides facial tactile sensation
Motor nucleus CNV
– Ovoid column of cells anteromedial to principal
sensory nucleus
– Supplies muscles of mastication (medial/lateral
pterygoids, masseter, temporalis), tensor veli
palatini/tensor tympani, mylohyoid, and anterior
belly of digastric
Spinal nucleus CNV
– Extends from principal sensory root in pons into
upper cervical cord (between C2 to C4 level)
– Conveys facial pain, temperature
Cisternal (Preganglionic) Segment
• 2 roots: Smaller motor, larger sensory

• Emerges from lateral pons at root entry zone (REZ)
• Courses anterosuperiorly through prepontine cistern
• Enters middle cranial fossa by passing beneath tentorium at
apex of petrous temporal bone
• Passes through opening in dura matter called porus
trigeminus to enter Meckel cave
Interdural Segment
• Meckel cave formed by meningeal layer of dura lined by
• Meckel cave formed by meningeal layer of dura lined by
arachnoid
Cave filled with cerebrospinal fluid (CSF) (90%) and
continuous with prepontine subarachnoid space
• Pia covers CNV in trigeminal cave
• Preganglionic CNV ends at trigeminal ganglion (TG)
TG located in inferior aspect of Meckel cave
TG synonyms: Gasserian or semilunar ganglion
Divisions (Postganglionic) of CNV
• Ophthalmic nerve
Courses in lateral cavernous sinus wall below CNIV
Exits skull through superior orbital fissure
Enters orbit, divides into lacrimal, frontal, and nasociliary
nerves
– Sensory innervation of scalp, forehead, nose, globe
• Maxillary nerve
Courses in cavernous sinus lateral wall below CNV1
Exits skull through foramen rotundum
Traverses roof of pterygopalatine fossa, inclines laterally
on back of maxilla, and enters orbit through inferior
orbital fissure
Continues as infraorbital nerve in floor of orbit
Exits orbit through infraorbital foramen
– Sensory innervation of cheek and upper teeth
• Mandibular nerve
Does not pass through cavernous sinus
Exits directly from Meckel cave, passing inferiorly
through foramen ovale into masticator space (MS)
Carries both motor and sensory fibers; motor root
bypasses TG, joins V3 as it exits through foramen ovale
Main trunk of CNV3 gives off meningeal branch and
nerve to medial pterygoid; latter provides nonrelaying
motor root to otic ganglion (OG), which supplies tensor
veli palatini and tensor tympani muscles
Lesser petrosal nerve (branch of tympanic plexus formed
by tympanic branch of glossopharyngeal nerve) provides
preganglionic parasympathetic supply to OG from
medullary inferior salivatory nucleus, and nonrelaying
sympathetic root is from plexus on middle meningeal
artery
Main trunk divides into small anterior division (giving
off masseteric, 2 deep temporal and nerve to lateral
pterygoid motor branches and buccal nerve sensory
branch) and large posterior division
Auriculotemporal nerve (secretomotor to parotid gland
via OG) arises from 2 roots of proximal posterior division
– 2 roots run backward encircling middle meningeal
artery and forming single trunk → again backward,
turning up behind neck of mandible and above
maxillary artery → then ascends on temple behind
superficial temporal vessels; sensory to external ear,
TMJ, parotid, temple, and secretomotor to parotid
via OG
Posterior division then divides into terminal branches:
Inferior alveolar (posterior) and lingual (anterior)
nerves
– Mylohyoid nerve (motor to anterior belly of
digastric and mylohyoid muscles) arises from
inferior alveolar nerve just before it enters mandible
and contains all motor fibers of posterior division of
V3
Lingual nerve (V3 sensory to anterior 2/3 of tongue, floor
of mouth) begins 1 cm below skull → runs between
tensor veli palatini and lateral pterygoid muscles → then
between lateral pterygoid and medial pterygoid → then
anteroinferiorly between medial pterygoid and
mandibular ramus → then in direct contact with
mandible medial to 3rd molar tooth → finally in lateral
sublingual space compartment
Chorda tympani nerve (VII nerve branch) distributed
through lingual nerve (taste to anterior 2/3 of tongue
and secretomotor to submandibular/sublingual salivary
glands via its preganglionic parasympathetic supply
from pontine superior salivatory nucleus to
submandibular ganglion); joins lingual nerve in MS 2 cm
below skull base after exiting from petrotympanic fissure

• CT best for skull base and bony foramina

• 3D T2 MR for intraaxial, cisternal, and intradural segments
• T1 C+ FS MR of entire extracranial course
Imaging Pitfalls
• TG is small crescent of tissue found in anteroinferior Meckel

cave
TG lacks blood-nerve barrier, therefore normally
enhances with contrast
Clinical Importance
• Sensory complaints: Pain, burning, numbness in face

• Motor (V3 only): Weakness in chewing
Proximal V3 injury causes motor atrophy of masticator
muscles within 6 weeks to 3 months
Distal V3 injury (above mylohyoid nerve takeoff) affects
only anterior belly of digastric and mylohyoid
• Tic douloureux (trigeminal neuralgia)
Sharp, excruciating pain in V2-3 distributions
Image Gallery
Print Images
GRAPHICS
Sagittal graphic shows the 4 nuclei of the trigeminal nerve

(CNV). From superior to inferior, note the mesencephalic
nucleus in the midbrain, the motor nucleus & main sensory
nucleus in the pons, & the spinal nucleus extending from the
lower pons into the upper cervical spinal cord. The motor
root of CNV sends fibers along the mandibular division only.
Axial graphic depicts the course of CNV from its pontine

nuclei (main sensory & motor nuclei) to its main 3 branches
(CNV1, CNV2, CNV3). Notice the large preganglionic
segment exiting the lateral pons at the root entry zone. It
then enters the Meckel cave through the porus trigeminus to
become the trigeminal ganglion. Vascular loop compression
of the root entry zone is the most common cause of
trigeminal neuralgia.
Coronal graphic shows the mandibular division of the

trigeminal nerve (CNV3), which never enters the cavernous
sinus. Instead, CNV3 exits directly from the Meckel cave,
passing inferiorly through the foramen ovale into the
nasopharyngeal masticator space. The Meckel cave is
actually a small anterior extension of the lateral prepontine
cistern, containing both the trigeminal nerve rootlets & the
trigeminal ganglion. Remember it is CNV3 that possesses
the motor fibers of the trigeminal nerve.
Coronal graphic through the cavernous sinus shows CNV2 in

the lateral wall of the cavernous sinus, just inferior to CNV1.
CNV1 is embedded in the lateral wall of the cavernous
sinus, as are CNIII and CNIV. The only centrally located
intracavernous cranial nerve is the abducens nerve (CNVI).
Sagittal graphic of CNV shows major branches & exiting
foramina. Ophthalmic division enters into orbit via superior
orbital fissure, dividing into frontal, nasociliary, & lacrimal
branches. Maxillary division exits via foramen rotundum.
Mandibular division exits through foramen ovale. Otic
ganglion (OG) lies just below skull base between CNV3 &
tensor veli palatini muscle. Lesser petrosal nerve provides
preganglionic parasympathetics to OG from medullary
inferior salivatory nucleus & sympathetic root is from plexus
on middle meningeal artery. Postganglionic secretomotor
fibers to parotid join auriculotemporal nerve (V3 branch).
Coronal graphic shows CNV3 exiting skull through foramen
ovale without entering cavernous sinus. Main trunk gives off
a meningeal branch & nerve to medial pterygoid & soon
divides into a small anterior division (giving rise to other
masticator muscle branches & a buccal sensory branch) & a
large posterior division, which gives rise to auriculotemporal,
inferior alveolar (gives off mylohyoid nerve), & lingual
nerves.
AXIAL BONE CT
First of 3 axial bone CT images presented from inferior to
superior through the central skull base is shown. CNV2 exits
the skull base through the foramen rotundum to enter the
superior margin of the pterygopalatine fossa. CNV3 exits via
the foramen ovale to enter the masticator space where it
supplies motor innervation to muscles of mastication &
sensory branches inferior alveolar, lingual, and
auriculotemporal nerves.
In this image, the foramen ovale (CNV3) and foramen
rotundum (CNV2) are now best seen on the patient's left.
The left foramen rotundum is seen opening into the superior
pterygopalatine fossa.
The superior orbital fissure transmits the ophthalmic division
of CNV from cranium to orbit. Other structures passing
through the superior orbital fissure include the oculomotor
nerve (CNIII), trochlear nerve (CNIV), abducens nerve
(CNVI), & the superior ophthalmic vein.
3T AXIAL T2 MR
First of 3 axial T2 MR images through CNV and Meckel
cave presented from inferior to superior shows a layer of
hypointense dura mater forming the lateral wall and roof of
Meckel cave. Right abducens nerve is seen penetrating
dura to enter the Dorello canal. CNV fascicles can be seen
with the cerebrospinal fluid of the Meckel cave.
Preganglionic fascicles of CNV are seen within the Meckel
cave, which is an arachnoid-lined, dural diverticulum
protruding from the lateral aspect of the prepontine cistern.
It contains cerebrospinal fluid, trigeminal fascicles, and
trigeminal ganglion. Note approximate location of the main
sensory and motor nuclei of CNV.
In this image, the preganglionic segment of CNV is seen
spanning the distance between the root entry zone on the
lateral pons and the porus trigeminus of the Meckel cave.
3T AXIAL T1 C+ MR
First of 3 axial T1 C+ FS MR images presented from
inferior to superior through the central skull base shows the
right maxillary nerve (CNV2) passing anteriorly into the
foramen rotundum and the left mandibular nerve (CNV3)
passing inferiorly through the foramen ovale. Both nerves
are surrounded by enhancing veins communicating with
extracranial venous system.
This more superior image demonstrates the ovoid shape of
the cerebrospinal fluid-filled Meckel cave. The trigeminal
ganglion is the linear anteroinferior structure in the Meckel
cave. It lacks a blood-nerve barrier and therefore normally
enhances with contrast.
Preganglionic segment of CNV arises from the lateral pons
at root entry zone. Right internal carotid artery is tortuous
within the cavernous sinus.
3T CORONAL T2 MR
to anterior shows the ovoid preganglionic segment of CNV
surrounded by high-signal cerebrospinal fluid. The
preganglionic segment has just exited the lateral pons root
entry zone area.
This more anterior image through the Meckel cave
delineates the trigeminal fascicles of the preganglionic
trigeminal nerve. The trigeminal ganglion is visible as a
semilunar structure in the floor of the Meckel cave
bilaterally.
This image through the anterior cavernous sinus shows the
maxillary nerve (CNV2) passing anteriorly within lateral wall
of the cavernous sinus and the mandibular nerve (CNV3)
passing inferiorly to its exit point in the skull base (foramen
ovale).
3T CORONAL T1 C+ MR
First of 6 coronal T1 C+ MR images through the cavernous
sinus presented from posterior to anterior is shown. The
trigeminal ganglion is seen as a crescentic area of
enhancement in the floor of the Meckel cave. Trigeminal
ganglion enhances because it lacks a blood-nerve barrier.
In this image through the foramen ovale, the mandibular
nerve (CNV3) is visible exiting inferiorly into the masticator
space.
In this image, the patient's left foramen ovale and
mandibular nerve are seen. The motor branches from CNV3
are to the medial pterygoid, which also supplies the tensor
veli palatini and tensor tympani (from main trunk), the
masseteric nerve, 2 deep temporal nerves to the temporalis
and nerve to the lateral pterygoid (from anterior division),
and the mylohyoid nerve, which supplies the mylohyoid and
anterior belly of the digastric muscles (branch of inferior
alveolar nerve; mylohyoid nerve contains all the motor fibers
of posterior division). The main sensory branches are the
meningeal branch (from main trunk), buccal nerve (from
anterior division), auriculotemporal nerve, and the terminal
lingual and inferior alveolar nerves (branches of posterior
division).
In this image through the anterior margin of the pituitary

gland, the maxillary nerve (CNV2) is well seen bilaterally in
the inferolateral wall of the cavernous sinus.
In this more anterior image, the maxillary nerves are seen in
the inferolateral wall of the cavernous sinus just prior to its
entry into the foramen rotundum. Inferomedially, note the
vidian canals.
In this image, the maxillary nerve can be seen in the
foramen rotundum. Notice also the vidian canal widening on
its extracranial side with the vidian nerve visible surrounded
by a venous plexus. The vidian nerve carries secretomotor
fibers originally in the facial nerve, which are responsible for
lacrimation.
3T SAGITTAL T2 AND AXIAL T1 MR

Sagittal T2 MR along the line of the proximal trigeminal
nerve shows the preganglionic segment between the root
entry zone in the lateral pons and the trigeminal ganglion in
the anteroinferior Meckel cave. The cerebrospinal fluid
within the Meckel cave communicates with the prepontine
cistern through the porus trigeminus.
First of 5 axial T1 unenhanced MR images extending from
the skull base to the mandibular body from superior to
inferior is shown. Notice the left maxillary nerve in the
foramen rotundum traverses the roof of pterygopalatine
fossa. It then inclines laterally on the back of maxilla and
enters the orbit through the inferior orbital fissure, after
which it continues as the infraorbital nerve in the floor of the
orbit that in turn exits the orbit through the infraorbital
foramen (not shown).
Image through the foramen ovale of the skull base is shown.
Notice the mandibular nerves exiting the skull base. The
vidian canal and nerve are also visible connecting the
foramen lacerum to the pterygopalatine fossa. The many
black dots within the pterygopalatine fossa are from the
normal terminal internal maxillary artery.
3T AXIAL T1 MR
Image just under the skull base shows mandibular nerves
entering medial upper masticator space. OG lies just below
skull base between CNV3 and tensor veli palatini muscle.
Main trunk of CNV3 gives off a meningeal branch and nerve
to medial pterygoid with motor root to OG and divides soon
into a small anterior division (giving off masseteric, 2 deep
temporal nerves to lateral pterygoid motor branches, and a
buccal nerve sensory branch) and a large posterior division.
Auriculotemporal nerve arises from 2 roots of the proximal
posterior division, runs backward encircling the middle
meningeal artery, and forms single trunk. The posterior
division then divides into terminal branches, inferior alveolar
(posterior) and lingual (anterior) nerves.
Image at level of mandibular foramina shows inferior
alveolar nerve runs downward lateral to medial pterygoid
and enters mandibular foramen, giving off mylohyoid nerve
just before entering mandible.
Image at mandible body level shows inferior alveolar nerve
course.
3T T2-SPACE MR
First from a series of 3 axial slices of a T2 sampling
perfection with application-optimized contrasts by using flip
angle evolution (SPACE) MR shows the trigeminal nerve
emerging from the brainstem.
Second in the series of axial slices of a T2-SPACE MR
shows the trigeminal nerve extending out of the brainstem.
Last in a series of 3 axial slices of a T2-SPACE MR shows
the trigeminal nerve projecting away from the brainstem.
3T MR
First in a series of 3 sagittal MR slices shows the trigeminal
nerve. The nerve is shown in bright contrast alongside the
temporal lobe on this T1 MP-RAGE MR.
Second in a series of 3 sagittal MR slices shows the
trigeminal nerve. The nerve is shown with dark contrast
alongside the temporal lobe on this T2 MR.
Last in a series of 3 sagittal MR slices shows the trigeminal
nerve. The nerve is shown with a superimposed 3D
tractography reconstruction created using diffusion tensor
imaging (DTI).
First in a series of 3 axial MR slices shows the trigeminal
nerve. The nerve is shown in bright contrast exiting the
brainstem.
Second in a series of 3 axial MR slices shows the trigeminal
nerve. The nerve is shown in dark contrast exiting the
brainstem.
Last in a series of 3 axial MR slices shows the trigeminal
nerve. The nerve is shown with a superimposed 3D
tractography reconstruction created using DTI.
3T DTI
First in a series of 3 axial slices from DTI data shows the
trigeminal nerve. The image is colored to indicate
orientation, where left-right fibers are colored in red,
anterior-posterior fibers are colored in green, and inferior-
superior fibers are colored in blue. The trigeminal nerve is
shown in green emerging from the brainstem.
Second in a series of 3 axial slices from DTI data shows the
trigeminal nerve in green exiting the brainstem.
Last in a series of 3 axial slices from DTI data shows the
trigeminal nerve in green outside the brainstem.
Abducens Nerve (CNVI)
Main Text
T ERM INOLOGY
Abbreviations
• Abducens nerve (CNVI)
Synonyms
• Abducens nerve: 6th cranial nerve
Definitions
• CNVI: Motor nerve to lateral rectus muscle only
IMAGING ANATOMY
Overview
• CNVI is pure motor nerve, longest intracranial course

• 5 segments : Intraaxial, cisternal, interdural, cavernous,
intraorbital (extracranial)
Abducens Nucleus
• Paired CNVI nuclei located in pontine tegmentum near

midline, just ventral to 4th ventricle
• Facial colliculus : Axons of facial nerve (CNVII) loop around
CNVI nucleus, creating bulge in floor of 4th ventricle
• Isolated lesion to facial colliculus can cause ipsilateral CNVI
& CNVII palsy
Intraaxial Segment
• Ipsilateral axons from CNVI nucleus course anteroinferiorly

through pontine tegmentum
Cisternal Segment
• Emerges from anterior brainstem near midline through

groove between pons & pyramid of medulla oblongata
(pontomedullary sulcus)
• Usually exits as single trunk but occasionally duplicated
• CNVI ascends anterosuperiorly in prepontine cistern
toward site where it penetrates dura along upper clivus
laterally
• Posterior to anterior inferior cerebellar artery in 85%;
anterior in 15%
Interdural Segment
• Extends from point where CNVI pierces inner layer dura

posteriorly to its entrance into cavernous sinus anteriorly
• Thin sleeve of arachnoid (& occasionally dura) travels with
nerve through this segment
• After penetrating dura, CNVI passes superiorly through
basilar venous plexus
Basilar venous plexus is dorsal to upper clivus & located
between inner & outer (endosteal) layers of dura; it is
interdural
• Nerve remains interdural & passes superiorly over junction
of petrous apex & clivus, into adjacent venous region known
as sphenopetroclival venous confluence [or simply
petroclival confluence or petroclival venous confluence
(PCVC)]
PCVC located at junction of posterior part of cavernous
sinus, lateral part of basilar plexus, & anterior part of
superior & inferior petrosal sinuses
• In this location, PCVC & interdural segment of CNVI are
considered to be within classic Dorello canal
• Classic Dorello canal is zone/space bounded by petrous
apex (inferolateral), clivus (inferomedial), & petrosphenoidal
ligament of Gruber (superiorly)
More recent descriptions in literature have proposed
modifications to classic description, often renaming
canal &/or expanding limits to include portions of
venous confluence above Gruber ligament, & making
posterior petroclinoid fold superior boundary
Cavernous Segment
• After exiting Dorello canal, CNVI enters cavernous sinus &

passes laterally around proximal aspect of cavernous
internal carotid artery (ICA)
• CNVI is only CN to lie within cavernous sinus, passing
lateral to cavernous ICA
• CNIII, CNIV, CNV1, & CNV2 are all embedded within
lateral wall of cavernous sinus
Intraorbital (Extracranial) Segment
• CNVI enters orbit through superior orbital fissure together

with CNIII & CNIV
• Passes through annulus of Zinn
• Supplies motor innervation to lateral rectus muscle
• MR for intraaxial, cisternal, interdural, cavernous segments

Thin-section, high-resolution T2 & contrast-enhanced T1
in axial & coronal planes; depicts small structures,
including CNs, surrounded by CSF with high contrast &
high spatial resolution
• Bone CT best for skull base & its bony foramina
Imaging Sweet Spots
• Axial & coronal MR sequences should include brainstem,

4th ventricle, cavernous sinus, & orbit
• CNVI nucleus & intraaxial segment not directly visualized
CNVI position inferred by identifying facial colliculus in
floor of 4th ventricle on high-res, thin-section T2 MR
• Cisternal segment routinely visualized on high-res T2 MR
• CNVI entrance into Dorello canal may be visualized due to
invagination of CSF into proximal canal
• Enhancement of basilar plexus may demonstrate CNVI as
tiny, linear, nonenhancing structures
Imaging Pitfalls
• Use of fat saturation on postcontrast T1 MR sequences can

amplify blooming (susceptibility) artifact around well-
aerated sphenoid sinus
Cavernous sinus & orbital apex subtle lesions may be
obscured by this artifact
Remove fat saturation & repeat T1 postcontrast MR if
this artifact obscures key areas of interest
Clinical Importance
• In CNVI neuropathy, affected eye will not abduct (rotate

laterally)
• CNVI neuropathy divided into simple if isolated & complex
if associated with other CN involvement (CNIII, CNIV, &
CNVII)
Simple CNVI neuropathy most common ocular motor
nerve palsy
Usually presents as complex cranial neuropathy
– Pontine lesions affect CNVI with CNVII
– Cavernous sinus, superior orbital fissure lesions
affect CNVI with CNIII, CNIV, & CNV1
Etiologies include tumor, aneurysm, trauma, ischemia, ↑
ICP, infection, demyelination
Image Gallery
Print Images
GRAPHICS
Axial graphic shows the entire length of the abducens nerve
(CNVI) from its pontine tegmentum nuclear origin to its
motor endplate in the lateral rectus muscle. Follow its
progress from nucleus to its exit at the anteromedial
bulbopontine sulcus. From there, note the dural penetration
into the Dorello canal leading to its intracavernous portion.
Finally, it passes through the superior orbital fissure and the
annulus of Zinn into the orbit.
Sagittal graphic shows CNVI depicted from its origin in the
pontine tegmentum to its motor endplate in the lateral rectus
muscle. Notice the intraaxial CNVI fibers descend before
exiting the bulbopontine sulcus anteriorly. Prepontine cistern
CNVI then ascends to pierce the dura into the Dorello canal.
Intracavernous CNVI proceeds anteriorly to pass through
the superior orbital fissure and the annulus of Zinn before
innervating the lateral rectus muscle in orbit.
3T AXIAL T2 & T1 C+ MR
Axial T2 MR near the level of the internal auditory canal is
presented to show the appearance of CNVI in the
prepontine cistern. On the patient's right, CNVI is just exiting
the bulbopontine sulcus, while on the left, it is poised to
penetrate the dura. Both nerves are rising in the prepontine
cistern.
Axial T1-enhanced MR demonstrates the interdural segment
of CNVI within the Dorello canal surrounded by brightly
enhancing basilar venous plexus at the level of the pons.
Axial T1-enhanced MR just above the internal auditory canal
shows CNVI passing through the superior basilar venous
plexus to enter the posterior margin of the cavernous sinus.
At this point, CNVI is arching over the petrous apex below
the petrosphenoidal ligament into the upper posterior region
of the cavernous sinus.
3T SAGITTAL T2 MR
First of 3 sagittal T2 MR images presented from lateral to
medial reveals the abducens nerve (CNVI) traversing the
prepontine cistern toward the clivus. In this image, CNVI is
visible penetrating the dura to enter the Dorello canal, which
lies between the cranial dura and periosteum surrounded by
basilar venous plexus.
Image of the brainstem area shows CNVI coursing
anterosuperiorly from its exit point from the brainstem
(bulbopontine sulcus) toward its point of dural penetration
into the Dorello canal. Notice the approximate location of
the CNVI nucleus and the steep course that the intraaxial
fibers take to reach the bulbopontine sulcus.
Image of the brainstem and prepontine cisterns shows the
proximal cisternal CNVI closely associated with the belly of
the pons. CNIII is seen passing between the posterior
cerebral and superior cerebellar arteries.
Facial Nerve (CNVII)
Main Text
T ERM INOLOGY
Abbreviations
• Facial nerve (CNVII)
Synonyms
Definitions
• CNVII: Cranial nerve that carries motor nerves to muscles of

facial expression; parasympathetics to lacrimal,
submandibular, and sublingual glands; and taste from
anterior 2/3 of tongue
IMAGING ANATOMY
Overview
• Mixed nerve: Motor, parasympathetic, and special sensory

(taste)
• 2 roots: Motor and sensory (nervus intermedius) roots
Nervus intermedius exits lateral brainstem between
motor root of facial and vestibulocochlear nerves, hence
its name
• 3 nuclei and 4 segments: Intraaxial, cisternal, intratemporal,
and extracranial (parotid)
Nuclei and Intraaxial Segment
• 3 nuclei (1 motor, 2 sensory)

• Motor nucleus of facial nerve
Located in ventrolateral pontine tegmentum
Efferent fibers loop dorsally around CNVI nucleus in
floor of 4th ventricle, forming facial colliculus
Fibers then course anterolaterally to exit lateral
brainstem at pontomedullary junction
• Superior salivatory nucleus
Located lateral to CNVII motor nucleus in pons
Efferent parasympathetic fibers exit brainstem posterior
to CNVII as nervus intermedius
– To submandibular, sublingual, and lacrimal glands
• Solitarius tract nucleus
Termination of taste sensation fibers from anterior 2/3 of
tongue
Cell bodies of these fibers in geniculate ganglion
Fibers travel within nervus intermedius
Cisternal Segment
• 2 roots in cisternal CNVII

Larger motor root anteriorly
Smaller sensory nervus intermedius posteriorly
• Emerge from lateral brainstem at root exit zone in
pontomedullary junction to enter cerebellopontine angle
(CPA) cistern
CNVIII exits brainstem posterior to CNVII
• 2 roots join together and pass anterolaterally through CPA
cistern with CNVIII to internal auditory canal (IAC)
Intratemporal Segment
• CNVII further divided in T-bone into 4 segments: IAC,

labyrinthine, tympanic, and mastoid
• IAC segment : Porus acusticus to IAC fundus;
anterosuperior position above crista falciformis
• Labyrinthine segment : Connects fundal CNVII to
geniculate ganglion (anterior genu)
• Tympanic segment : Connects anterior to posterior genu,
passing under lateral semicircular canal
• Mastoid segment : Inferiorly directed from posterior genu to
stylomastoid foramen
• Main CNVII exits skull base through stylomastoid foramen

to enter parotid space
• Parotid CNVII passes lateral to retromandibular vein
• Ramifies within parotid, passes anteriorly to innervate
muscles of facial expression
CNVII Branches
• Greater superficial petrosal nerve

Arises at geniculate ganglion, passes anteromedially,
exits temporal bone via facial hiatus
Carries parasympathetic fibers to lacrimal gland
• Stapedius nerve
Arises from high mastoid segment of CNVII
Provides motor innervation to stapedius muscle
• Chorda tympani nerve
Arises from lower mastoid segment
Courses across middle ear to exit anterior T-bone
Carries taste fibers from anterior 2/3 of tongue
– These fibers travel with lingual branch of mandibular
division of trigeminal nerve
• Terminal motor branches to muscles of facial expression
Superior to inferior: Temporal, zygomatic, buccal,
mandibular, cervical

• Bone CT best for intratemporal segment of CNVII

• MR for intraaxial, cisternal, IAC, and extracranial segments
• Do not image routine Bell palsy!
Imaging Sweet Spots
• Include brainstem, CPA cistern, IAC, T-bone, and parotid

when MR completed for CNVII palsy
Imaging Pitfalls
• Mild enhancement of labyrinthine segment, geniculate

ganglion, and proximal tympanic segments of CNVII can be
normal on postcontrast T1 MR
Secondary to circumneural arteriovenous plexus
• Always check parotid in peripheral CNVII paralysis
Clinical Issues
• Facial nerve paralysis can be central or peripheral

Central : Supranuclear injury resulting in paralysis of
contralateral muscles of facial expression with forehead
sparing
Peripheral : Injury to CNVII from brainstem nucleus
peripherally, resulting in paralysis of all ipsilateral
muscles of facial expression
– If lesion proximal to geniculate ganglion, lacrimation,
sound dampening, and taste affected
– If CNVI involved, check pons for lesion
– If CNVIII involved, check CPA-IAC for lesion
– If lacrimation, sound dampening, and taste are
variably affected, T-bone lesion possible
– If lacrimation, sound dampening and taste are
spared, extracranial CNVII implicated
Image Gallery
Print Images
GRAPHICS
Axial graphic shows CNVII nuclei. Motor nucleus sends out
its fibers to circle CNVI nucleus before reaching root exit
zone at the pontomedullary junction. The superior salivatory
nucleus sends parasympathetic secretomotor fibers to the
lacrimal, submandibular, and sublingual glands. Solitary
tract nucleus receives anterior 2/3 of tongue taste
information.
Sagittal graphic depicts CNVII within the temporal bone.
Motor fibers pass through the temporal bone, dropping the
stapedius nerve to the stapedius muscle, then exit via the
stylomastoid foramen to extracranial CNVII (entirely motor).
Parasympathetic fibers from superior salivatory nucleus
reach the lacrimal gland via the greater superficial petrosal
nerve and submandibular-sublingual glands via the chorda
tympanic nerve. The anterior 2/3 of tongue taste fibers
come via the chorda tympani nerve.
Sagittal graphic depicts extracranial motor branches of the
facial nerve.
AXIAL BONE CT
First of 6 axial bone CT of the left temporal bone presented
from superior to inferior shows the labyrinthine segment of
the facial nerve canal as a C-shaped structure arching
anterolaterally over the top of the cochlea.
In this image, the labyrinthine segment of CNVII canal
terminates in the geniculate fossa. The facial nerve canal
turns abruptly at the geniculate fossa (anterior genu). The
tympanic segment arises from the geniculate fossa,
coursing posterolaterally in the axial plane, running under
the lateral semicircular canal before turning 90° inferiorly at
the posterior genu to become the mastoid segment.
At the level of the oval window, the mastoid segment is
visible deep to the facial nerve recess. Notice the more
medial pyramidal eminence and sinus tympani.
Mastoid segment extends ~ 13 mm from the posterior genu
to the stylomastoid foramen, coursing inferiorly within the
posterior wall of the middle ear cavity. The mastoid
segment is related anteriorly to the facial nerve recess and
medially to the stapedius muscle within the pyramidal
eminence on the posterior wall of the middle ear cavity.
At the level of the basal turn of the cochlea, the mastoid
segment of the facial nerve is still visible. Both the nerve to
the stapedius muscle proximally and the chorda tympani
distally branch off the mastoid segment (CNVII).
Image at the level of the stylomastoid foramen is shown.
Notice the "bell" of the stylomastoid foramen is just
anteromedial to the mastoid tip. The mastoid tip protects
the facial nerve from traumatic injury as it exits the skull
base.
CORONAL BONE CT
First of 6 coronal bone CT of the left temporal bone
presented from posterior to anterior shows the lower
mastoid segment of the facial nerve (CNVII) and
stylomastoid foramen.
At the level of the round window, the posterior genu of the
facial nerve can be seen just lateral to the pyramidal
eminence. Notice the sinus tympani is medial to the
pyramidal eminence.
At the level of the oval window, the tympanic segment of the
facial nerve can be seen coursing under the lateral
semicircular canal. Notice the fine bony covering (thin white
line) surrounding the facial nerve. Also note the location
relative to the upper margin of the oval window. In patients
with oval window atresia, the facial nerve is found near or
within the oval window niche.
At the level of the anterior margin of the oval window, the
tympanic segment of the facial nerve can be seen under the
lateral semicircular canal. Notice the fine bony covering (thin
white line) surrounding the facial nerve is now not seen. The
facial nerve canal bony covering in this area is normally
incomplete.
In the anterior middle ear cavity, the labyrinthine segment of
the facial nerve can be seen exiting the internal auditory
canal over the top of the cochlea. The anterior tympanic
segment of the facial nerve is also visible. Do not confuse
the muscle-tendon of the tensor tympani in the
cochleariform process with the facial nerve.
In the most anterior portion of middle ear cavity (where both
the carotid and the cochlea are visible), the geniculate
ganglion is seen within the geniculate fossa as an ovoid
structure just above the cochlea.
3T AXIAL T2 & T1 MR
First of 2 axial high-resolution T2 MR through the
cerebellopontine angle cistern and internal auditory canal is
shown. The facial nerve root exit zone is seen anterior to
the vestibulocochlear nerve in the pontomedullary junction
bilaterally. Notice the facial nerve maintains an anterior
relationship with the vestibulocochlear nerve as it crosses
through the cerebellopontine angle cistern.
Image through the cephalad internal auditory canal on the
patient's left shows the facial nerve anterior to the superior
vestibular nerve throughout its internal auditory canal
course.
Axial T1 MR at the level of the stylomastoid foramen shows
the exiting low-signal facial nerve surrounded by high-signal
fat in the "bell" of the stylomastoid foramen. If perineural
parotid malignancy is present, the fat in this area is
obscured.
3T OBLIQUE SAGITTAL T2 MR
First of 3 oblique sagittal T2 MR presented from lateral to
medial shows normal fundal anatomy. The horizontal crista
falciformis separates the fundus into the upper and lower
portions. The facial nerve is anterosuperior, separated from
the superior vestibular nerve by a vertical bony septum
called the "Bill bar," which is not resolved. Below the
falciform crest are the larger anterior cochlear nerve and
posterior inferior vestibular nerve.
In the midinternal auditory canal, 4 nerves are clearly
identified. The facial nerve is anterosuperior.
This image through the porus acusticus reveals the
characteristic ball in a catcher's mitt appearance of the
facial and vestibulocochlear nerves. The facial nerve is the
"ball" and the vestibulocochlear nerve is the "catcher's mitt."
3T T2-SPACE MR
First of a series of 3 axial slices of a T2 sampling perfection
with application-optimized contrasts by using flip angle
evolution (T2-SPACE) MR showing the facial nerve.
Second in the series shows a more superior axial T2-
SPACE MR slice through the facial nerve.
Third in the series shows a detailed view of an axial T2-
SPACE MR slice through the facial nerve. The facial nerve
was manually segmented and rendered in 3D in pink. The
cochlear and vestibular nerves are also partially visible in
green and orange, respectively.
3T MR
A 3D surface rendering from T2-SPACE MR of the facial
(CNVII) and vestibulocochlear nerve (CNVIII) is shown. The
facial nerve was manually segmented and rendered in 3D in
pink. The cochlear and vestibular nerves are also partially
visible in green and orange, respectively.
First of 2 axial sections of a diffusion tensor imaging (DTI)
dataset shows the facial nerve along with white matter
pathways. The image is colored to indicate orientation,
where left-right fibers are colored in red, anterior-posterior
fibers are colored in green, and inferior-superior fibers are
colored in blue. Note: The facial nerve (CNVII) cannot be
visibly discerned from the vestibulocochlear nerve (CNVIII)
at this resolution.
Second of 2 axial sections of a DTI dataset showing the
facial nerve along with white matter pathways is shown. The
facial nerve (CNVII) was modeled using diffusion
tractography (orange). Note: The facial nerve (CNVII)
cannot be visibly discerned from the vestibulocochlear nerve
(CNVIII) at this resolution.
Vestibulocochlear Nerve (CNVIII)
Main Text
T ERM INOLOGY
Abbreviations
• Vestibulocochlear nerve (CNVIII)
Synonyms
Definitions
• CNVIII: Afferent sensory nerve of hearing & balance
IMAGING ANATOMY
Overview
• Sensory (special sensory afferent) nerve consisting of 2 parts

Vestibular part: Balance
Cochlear part: Hearing
• CNVIII best described from peripheral to central
Cochlear Nerve
• Arises from bipolar neurons located in spiral ganglion

within modiolus of cochlea
Peripheral fibers pass to organ of Corti in cochlear duct
(scala media) within cochlea
Central fibers coalesce & pass as auditory component of
CNVIII (cochlear nerve) to brainstem
• Central fibers pass from modiolus through cochlear aperture
into internal auditory canal (IAC)
Cochlear aperture defined as bony opening into
anteroinferior quadrant of fundus of IAC
Maximum diameter of cochlear aperture: ~ 2 mm
• Cochlear nerve passes from IAC fundus to porus acusticus
within anteroinferior q uadrant of IAC
• Near porus acusticus cochlear nerve joins together with
superior & inferior vestibular nerves to form
vestibulocochlear nerve (CNVIII)
• CNVIII crosses cerebellopontine angle (CPA) cistern
posterior to facial nerve
• CNVIII enters lateral brainstem at pontomedullary junction
• Cochlear nerve fibers bifurcate, ending in dorsal & ventral
cochlear nuclei
• Dorsal & ventral cochlear nuclei
Cochlear nuclei found on lateral surface of inferior
cerebellar peduncle (restiform body)
Vestibular Nerve
• Arises from bipolar neurons located in vestibular (Scarpa)

ganglion located within vestibular nerve in fundal portion of
IAC
Vestibular ganglion not visible on imaging
Peripheral fibers pass to sensory epithelium of utricle,
saccule, & semicircular canals
– Traverse multiple foramina in cribriform plate in
lateral wall of IAC fundus
Central fibers coalesce to form superior & inferior
vestibular nerves that pass medially to brainstem
• Fundus of IAC
Superior & inferior vestibular nerves are separated by
falciform crest (transverse crest)
Superior vestibular nerve separated from facial nerve
anteriorly by vertical bony structure called Bill bar
– Bill bar not visible on imaging (CT or MR)
• Superior & inferior vestibular nerves pass medially from IAC
fundus to porus acusticus within posterosuperior &
posteroinferior quadrants of IAC
• Near porus acusticus, superior & inferior vestibular nerves
join together with cochlear nerve to form vestibulocochlear
nerve (CNVIII)
• Vestibulocochlear nerve crosses CPA cistern posterior to
facial nerve
• Enters lateral brainstem at junction pons & medulla
• Vestibular nerve fibers divide into ascending & descending
branches, which mainly terminate in vestibular nuclear
complex
• Vestibular nuclear complex
4 nuclei (lateral, superior, medial, & inferior)
Located beneath lateral recess along floor of 4th ventricle
(rhomboid fossa) in lower pons
Complex connections exist between vestibular nuclei,
cerebellum, spinal cord (vestibulospinal tract), & nuclei
controlling eye movement

• Sensorineural hearing loss (SNHL)
Intracochlear lesion suspected
– CT & MR both useful for imaging
– Congenital lesions of membranous labyrinth seen as
abnormalities of fluid spaces on MR or in bony
labyrinth shape on T-bone CT
– T-bone CT better for otosclerosis, Paget disease,
labyrinthine ossificans, or if trauma suspected
– Only MR will demonstrate labyrinthitis or
intralabyrinthine tumor
CNVIII lesion suspected (CPA-IAC)
– MR imaging method of choice
– Thin-section, high-resolution T2 sequence in axial &
coronal planes may be used to screen patients with
unilateral SNHL
– T1 C+ MR remains gold standard
Imaging Sweet Spots
• Unilateral SNHL
Focus on brainstem (inferior cerebellar peduncle)-CPA-
IAC-cochlea
Central acoustic pathway (intraaxial pathways above
cochlear nuclei) rarely site of offending lesion
• Cisternal & IAC segments of CNVIII routinely visualized on
high-resolution T2 MR
Imaging Pitfalls
• Beware small lesions of IAC (≤ 2 mm)

Follow-up imaging recommended as may be transient
finding where surgery not needed
Clinical Importance
• Vestibular nerve dysfunction (dizziness, vertigo, imbalance)

alone usually has negative MR
• 95% of lesions causing unilateral SNHL found by MR are
vestibulocochlear schwannoma
Image Gallery
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GRAPHICS
Axial graphic of the cerebellopontine angle (CPA), internal
auditory canal (IAC), & inner ear is shown. Cochlear
component of CNVIII begins in bipolar cell bodies in spiral
ganglion of cochlear modiolus. Central fibers run in the
cochlear nerve to dorsal & ventral cochlear nuclei in the
inferior cerebellar peduncle. The inferior & superior
vestibular nerves begin in cell bodies in the vestibular
ganglion, from there coursing centrally to 4 vestibular nuclei.
Axial graphic of magnified cochlea, modiolus, & cochlear
nerve is shown. Notice the bipolar spiral ganglion cells within
modiolus contribute distal fibers to the organ of Corti as well
as proximal axons that constitute the cochlear nerve.
Graphic depicting fundus of the IAC is shown. Notice the
crista falciformis separates the cochlear nerve & inferior
vestibular nerve below from CNVII & superior vestibular
nerve above. Also note Bill bar separating CNVII from the
superior vestibular nerve.
AXIAL & CORONAL BONE CT

Axial bone CT through the upper portion of the IAC shows
the C-shaped labyrinthine segment of the facial nerve & a
main canal of the superior vestibular nerve crossing the
cribriform plate toward the vestibule.
Axial bone CT through the lower IAC shows anterolateral
cochlear aperture through which the cochlear nerve passes
on its way from the cochlear modiolus into the IAC. Also
notice the cribriform plate foramen through which the inferior
vestibular nerve reaches the vestibule & the smaller singular
canal.
Coronal bone CT through the IAC demonstrates the
horizontal falciform crest, which divides the fundus of the
IAC into upper & lower portions. Facial & superior vestibular
nerves pass above, & cochlear & inferior vestibular nerves
pass below the falciform crest. Porus acusticus is a bony
aperture of the IAC.
3T AXIAL T2 MR
superior through the CPA cistern & IAC is shown. Section
through the superior left IAC demonstrates the cochlear
nerve anteriorly & inferior vestibular nerve posteriorly at the
fundus.
Vestibulocochlear nerve arises posterior to the facial nerve
from the brainstem at the pontomedullary junction &
maintains a posterior position throughout its course through
the CPA/IAC. On the patient's right, the cochlear nerve is
anterior to inferior vestibular nerve within the fundus of the
IAC. On the left, the superior fundus of the IAC is seen with
the anterior facial nerve & posterior superior vestibular
nerve.
MR slice through the superior IAC area demonstrates the
superior vestibular nerve posterior to facial nerve on the
patient's right.
3T CORONAL T2 MR
to anterior is shown. Vestibulocochlear nerve emerges from
the brainstem posterior to the facial nerve at the
pontomedullary junction.
Facial & vestibulocochlear nerves course through the CPA
into the IAC. Facial nerve is anterior & superior to the
vestibulocochlear nerve within the CPA & IAC. Notice the
somewhat cephalad course of CNVIII as it rises into the
IAC from its origin at the pontomedullary junction.
Section through the fundus of the IAC demonstrates the
horizontal falciform crest separating the fundus into upper &
lower portions. At this level, the facial nerve is above & the
cochlear nerve is below the falciform crest. The
anteroinferior cerebellar artery loop is a constant fixture in
the normal anatomy of the CPA & IAC area.
3T OBLIQUE SAGITTAL T2 MR
First of 3 sequential oblique sagittal T2 MR images through
the IAC presented from lateral to medial is shown. Slice is
through the fundus of the IAC showing the horizontal
falciform crest separating the fundus into upper & lower
portions. Facial nerve is anterosuperior, separated from the
superior vestibular nerve by a vertical bony septum called
"Bill bar," which is not resolved with even focused imaging.
Below the falciform crest are the cochlear nerve anteriorly &
inferior vestibular nerve posteriorly.
In the mid-IAC, this image shows 4 discrete nerves.
At the level of porus acusticus, both the superior & inferior
vestibular nerves join together with the cochlear nerve to
form a C-shaped vestibulocochlear nerve. The facial nerve
remains discrete as it travels across the CPA cistern.
3T T2-SPACE MR
First of 3 axial slices of a T2 sampling perfection with
application-optimized contrasts by using flip angle evolution
(T2-SPACE) MR showing the vestibulocochlear nerve is
depicted here.
Second in the series shows a more inferior axial T2-SPACE
MR slice through the vestibulocochlear nerve.
Third in the series shows a detailed view of an axial T2-
SPACE MR slice. The cochlear and vestibular nerves were
manually segmented and rendered in 3D, in green and
orange, respectively. The facial nerve is also shown in pink.
3T MR
3D surface rendering from T2-SPACE MR of the facial and
vestibulocochlear nerve is shown. The facial nerve was
manually segmented and rendered in 3D in pink. The
cochlear and vestibular nerves are also partially visible in
green and orange, respectively.
First of 2 views of an axial section of a DTI dataset showing
the vestibulocochlear nerve alongside white matter
pathways is depicted. The image is colored to indicate
orientation, where left-right fibers are colored in red,
anterior-posterior fibers are colored in green, and inferior-
superior fibers are colored in blue. The vestibulocochlear
and facial nerves cannot be visibly discriminated at this
resolution.
Second view of an axial section of a DTI dataset showing
the vestibulocochlear nerve along with white matter
pathways is depicted. The vestibulocochlear nerve was
modeled using diffusion tractography (orange). The facial
nerve cannot be visibly discriminated from the
vestibulocochlear nerve at this resolution.
Glossopharyngeal Nerve (CNIX)
Main Text
T ERM INOLOGY
Abbreviations
• Glossopharyngeal nerve (CNIX)
Synonyms
Definitions
• Mixed nerve with complex functions

Taste & sensation to posterior 1/3 of tongue
Sensory nerve to middle ear & pharynx
Parasympathetic to parotid gland
Motor to stylopharyngeus muscle
Viscerosensory to carotid body & sinus
IMAGING ANATOMY
Overview
• 4 segments: Intraaxial, cisternal, skull base, & extracranial
Intraaxial Segment
• Glossopharyngeal nuclei are in upper & middle medulla
Motor fibers to stylopharyngeus muscle originate in
nucleus ambiguus
Sensory fibers from tympanic membrane, soft palate,
tongue base, & pharynx terminate in spinal nucleus
CNV
Taste fibers from posterior 1/3 of tongue terminate in
solitary tract nucleus
Parasympathetic fibers to parotid gland originate in
inferior saliva to ry nucleus
Cisternal Segment
• Exits lateral medulla in postolivary sulcus as 3-5 rootlets

uniting to form cisternal segment just above vagus nerve
• Nerve length from medulla to jugular foramen is ~ 14-18 mm
• Transition zone (TZ) located ~ 1.1-1.8 mm from medulla or
root entry/exit zone (REZ)
TZ is area between central & peripheral myelin with
increased vulnerability to mechanical irritation &
relevant in neurovascular compression
REZ is portion of nerve, including TZ, central myelin root
portion, & adjacent brainstem surface
Glossopharyngeal neuralgia caused by neurovascular
compression occurs 95% in proximal REZ, overlapping
proximal location of TZ
• Nerve travels anterolaterally through basal cistern with
vagus nerve & bulbar portion of accessory nerve
• Passes through glossopharyngeal meatus into pars nervosa
portion of jugular foramen
Skull Base Segment
• Passes through anterior pars nervosa

• Passes through anterior pars nervosa
Accompanied by inferior petrosal sinus
CNX & CNXI are posterior within pars vascularis of
jugular foramen
Superior & inferior sensory ganglia of CNIX within
jugular foramen
• Exits into anterior nasopharyngeal carotid space

• Passes lateral to internal carotid artery, innervates
stylopharyngeus, & contributes to carotid sinus nerve
• Gives branches to pharyngeal plexus & terminates as
tonsillar and lingual branches
Extracranial Branches
• Tympanic branch (Jacobson nerve)

Sensation from middle ear & parasympathetic to parotid
gland via lesser petrosal nerve & otic ganglion
Arises from inferior sensory ganglion in jugular foramen
Via inferior tympanic canaliculus to hypotympanum
– Aberrant internal carotid artery enters via this canal
Forms tympanic plexus on cochlear promontory
– Glomus bodies associated with this nerve form
glomus tympanicum paraganglioma
• Stylopharyngeus branch
Motor to stylopharyngeus muscle
Muscle function: Elevate larynx, pharynx & dilate
pharynx
• Carotid sinus nerve
Supplies viscerosensory fibers to carotid sinus & body
Conducts impulses from mechanoreceptors of sinus &
chemoreceptors of carotid body to medulla
• Pharyngeal branches
Sensory to posterior oropharynx & soft palate
(pharyngeal plexus)
• Lingual branch
Sensory & taste to posterior 1/3 of tongue

• MR imaging method of choice

Superior sensitivity to skull base, meningeal, cisternal, &
brainstem pathology
Sequences should include combination of T2, T1 without
fat saturation, & contrast-enhanced T1 with fat
saturation in axial & coronal planes
• Supplemental bone CT for complex skull base pathology
Imaging Sweet Spots
• Image from pontomedullary junction to hyoid bone

• CNIX nuclei & intraaxial segment not directly visualized
Position inferred by identifying upper medulla, posterior
to postolivary sulcus
Cisternal segment not always visualized on routine MR
– High-resolution, thin-section T2 sequences often
identify cisternal segments of CNIX-XI nerve
complex
– Bone algorithm CT for bony anatomy of pars
nervosa
• Extracranial segment not visualized
Imaging Pitfalls
• Remember to image entire extracranial course of CNIX

• Remember to image entire extracranial course of CNIX
beyond skull base!
Clinical Importance
• Complex CNIX-XI neuropathies (Vernet syndrome) caused

by disease in medulla, basal cistern, jugular foramen, or
nasopharyngeal carotid space
Isolated CNIX neuropathy exceedingly rare
• Glossopharyngeal neuralgia mostly caused by compression
by posterior inferior cerebellar artery (PICA) > anterior ICA
(AICA); minority from trauma, neoplasm, infection, multiple
sclerosis, or elongated styloid process (Eagle syndrome)
• Palatal myoclonus associated with hypertrophic olivary
degeneration (HOD)
Image Gallery
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GRAPHICS
Posterior view of the brainstem emphasizing the 4 nuclei
participating in the functions of the glossopharyngeal nerve
is shown. Notice the 2 efferent nuclei, the nucleus ambiguus
and inferior salivatory nucleus labeled on the right. The
nucleus ambiguus supplies motor fibers to the
stylopharyngeus muscle, while the inferior salivatory nucleus
supplies parasympathetic fibers to the parotid gland. On the
left, the afferent nuclei are the solitary tract nucleus and the
spinal nucleus of CNV. The solitary tract nucleus receives
taste fibers from the tongue base, while the spinal nucleus
of CNV receives sensation from the middle ear, soft palate,
tongue base, and pharynx.
Axial graphic through medullary brainstem from above
shows the 4 nuclei of the glossopharyngeal nerve. Note the
location of CNIX within the pars nervosa of the jugular
foramen, separated from the pars vascularis by the jugular
spine.
GRAPHIC, EXTRACRANIAL
Graphic of skull base viewed from below depicting the 4
cranial nerves emerging into the nasopharyngeal carotid
space is shown. The glossopharyngeal nerve (CNIX) is just
anteromedial to the internal jugular vein as it exits the pars
nervosa of the jugular foramen.
Axial graphic of nasopharyngeal carotid spaces shows the
extracranial glossopharyngeal nerve situated anteriorly in
the gap between the internal carotid artery and the internal
jugular vein. Notice that at this level, CNX, CNXI, and CNXII
are all still within the carotid space. The glossopharyngeal
nerve exits the carotid space at the level of the high
oropharynx.
Sagittal graphic emphasizing the extracranial component of
the glossopharyngeal nerve is shown. Only 1 muscle is
innervated by the fibers in CNIX from the nucleus ambiguus,
the stylopharyngeus. Sensory information from the middle
ear, tongue base, soft palate, and oropharyngeal surface is
transmitted via CNIX to the spinal nucleus of the trigeminal
nerve. Taste sensation from the tongue base travels via
CNIX to the solitary tract nucleus. Parasympathetic
secretomotor fibers from the inferior salivatory nucleus
bound for the parotid gland also travel in CNIX.
AXIAL BONE CT
First of 3 axial bone CT images presented from inferior to
superior through posterior skull base emphasizes the bony
anatomy of the jugular foramen. The jugular foramen is
located on the floor of the posterior cranial fossa between
the petrous temporal bone anterolaterally and the occipital
bone posteromedially, a venous channel between these
bones.
The jugular foramen is seen here as 2 discrete pieces, the
smaller anteromedial pars nervosa and larger posterolateral
pars vascularis, separated by the jugular spine of petrous
bone.
The 2 parts of the jugular foramen are visibile. The pars
nervosa transmits the glossopharyngeal nerve (CNIX),
Jacobsen nerve, and inferior petrosal sinus. The pars
vascularis transmits the vagus (CNX) and accessory (CNXI)
cranial nerves, Arnold nerve, and sigmoid sinus, which
becomes the internal jugular vein.
3T AXIAL T2 MR
First of 3 axial high-resolution T2 MR images through the
brainstem medulla presented from inferior to superior is
shown. Glossopharyngeal nerve is seen passing laterally
into the pars nervosa of the jugular foramen.
The glossopharyngeal nerve (CNIX), vagus nerve (CNX),
and bulbar accessory nerve (CNXI) all exit the medulla
laterally in the postolivary sulcus. CNIX is the most cephalad
of these. With routine MR imaging, it is not possible to see
these 3 cranial nerves individually.
In the upper medulla, the vagus nerve (CNX) is well seen
leaving the brainstem via the postolivary sulcus. The
glossopharyngeal nerve (CNIX) is seen more laterally, as it
has already exited the brainstem above the vagus nerve.
Vagus Nerve (CNX)
Main Text
T ERM INOLOGY
Abbreviations
• Vagus nerve (CNX)
Definitions
• CNX: Longest and one of most complex cranial nerves (CN)

with diverse functions, including parasympathetic (PS)
innervation of neck, thoracic and abdominal viscera
• Involved in autonomic regulation of cardiovascular,
respiratory, and gastrointestinal systems
• Additional innervation
Motor to majority of soft palate, pharynx, larynx, and
palatoglossus tongue muscle
Visceral sensation from larynx, esophagus, trachea,
thoracic and abdominal viscera
Sensory nerve to external tympanic membrane (TM),
external auditory canal (EAC), and external ear
Taste from epiglottis
IMAGING ANATOMY
Overview
• Longest of CN, extending from medulla to colon
• Segments: Intraaxial, cisternal, skull base, and extracranial
Intraaxial Segment
• Vagal nuclei are in upper and middle medulla

Motor fibers originate in nucleus ambiguus
Taste from epiglottis goes to solitary tract nucleus
Sensory fibers from viscera go to dorsal vagal nucleus
(afferent component)
PS fibers project from dorsal vagal nucleus (efferent
component)
Sensations from meninges and ear to spinal nucleus
CNV
Cisternal Segment
• Nerve fibers exit lateral medulla in postolivary sulcus

inferior to CNIX and superior to bulbar portion of CNXI
Skull Base Segment
• Enters pars vascularis portion of jugular foramen (JF)

With CNXI (shared fibrous sheath) and jugular bulb
Superior vagal (jugular) ganglion is found within JF
• Exits JF into nasopharyngeal carotid space

• Inferior vagal (nodose) ganglion lies just below skull base
• Travels posterolateral to carotid artery into thorax
Passes anterior to aortic arch on left and subclavian
artery (SCA) on right
• Forms plexus around esophagus and major blood vessels to
heart and lungs
• Esophageal plexus nerves provide PS supply to stomach
• Innervation to intestines and visceral organs follows arterial
blood supply
Extracranial Branches in Head and Neck
• Auricular branch (Arnold nerve)

Sensation from external surface of TM, EAC, external ear
Arises from superior vagal ganglion within JF, also has
CNIX branches
Passes through mastoid canaliculus extending from
posterolateral JF to mastoid segment CNVII canal
Enters EAC via tympanomastoid fissure
• Pharyngeal branches
Pharyngeal plexus exits just below skull base
Sensory to epiglottis, trachea, and esophagus
Motor to soft palate [except tensor veli palatini muscle
(CNV3)] and pharyngeal constrictor muscles
Carotid sinus branch (Hering nerve)
– Formed by small CNIX branch and branch from
CNX
– Supplies carotid sinus wall baroreceptors and
carotid body chemoreceptors
• Superior laryngeal nerve
Motor to cricothyroid muscle (external branch)
Sensory internal branch to hypopharynx and
supraglottis
• Recurrent laryngeal nerve (RLN)
On right, recurs at cervicothoracic junction, passes
posteriorly around SCA
On left, recurs in mediastinum, passes posteriorly under
aorta at aortopulmonary window (APW)
Travels in tracheoesophageal groove (TEG)
posteromedial to thyroid lobe and enters larynx at
cricothyroid joint level
Motor to all laryngeal muscles except cricothyroids
Sensory to mucosa of infraglottis

• Proximal vagal neuropathy

Image from medulla to hyoid bone
MR imaging method of choice: Superior sensitivity for
skull base, meningeal, cisternal, and brainstem
pathology
– Should include axial and coronal T2, T1 (without fat
saturation and contrast enhanced with fat
saturation)
– Include heavily T2-weighted steady state (FIESTA or
CISS) sequence
– Bone CT complimentary in complex skull base
pathology
• Distal vagal neuropathy
Image skull base to mediastinum; to carina for left side
Key areas to evaluate are carotid space, TEG, APW
CECT imaging method of choice
Clinical Importance
• Vagal nerve dysfunction: Proximal symptom complex

Injury site: Between medulla and hyoid bone
Multiple CN involved (CNIX-XII, Vernet syndrome) with
oropharyngeal and laryngeal dysfunction
• Vagal nerve dysfunction: Distal symptom complex
Injury site: Below hyoid bone
Isolated larynx dysfunction with vocal cord (VC)
paralysis (RLN involvement > > infrahyoid CNX)
Imaging features of VC paralysis: Medialization of
ipsilateral true VC, anteromedial arytenoid cartilage
rotation, enlarged laryngeal ventricle = sail sign,
medialized, thickened aryepiglottic fold, enlarged
pyriform sinus
• Non-RLN : Rare, enters larynx without thoracic descent (>
common right with aberrant right SCA), can get injured
during thyroid/spine surgery
Image Gallery
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GRAPHICS, PROXIMAL CNX
Graphic of brainstem viewed from behind shows critical
nuclear columns of CNX. Note the nucleus ambiguus
supplies motor fibers to CNX. Dorsal vagal nucleus is a
mixed nucleus, sending efferent parasympathetic fibers to
the viscera while receiving afferent sensory fibers from
these same viscera. The solitary tract nucleus receives
taste information from the epiglottis and vallecula via CNX.
Axial graphic through the medulla shows principal nuclei
associated with vagus nerve function. Skeletal motor fibers
to pharynx and larynx come from the nucleus ambiguus.
Parasympathetic fibers to the viscera are associated with
the dorsal nucleus of the vagus nerve (solid pink line).
Sensory information transmitted from the viscera is also
transmitted to the dorsal nucleus of the vagus nerve
(dashed pink line). The solitary tract nucleus receives taste
information for the epiglottis.
GRAPHIC, EXTRACRANIAL VAGUS NERVE

Lateral graphic is focused on the neck and upper
mediastinal portions of CNX, including the 4 brainstem
nuclei. The nucleus ambiguus supplies efferent motor
innervation (green lines) via the pharyngeal plexus to the
soft palate and pharynx (superior, middle, and inferior
constrictor muscles) and via the recurrent laryngeal nerves
to all laryngeal muscles except the cricothyroids. The dual-
functioning dorsal vagal nucleus both sends out efferent
fibers for involuntary motor activity in the viscera (solid pink
line) and receives sensations from these same viscera
(dashed pink line). The solitary tract nucleus receives taste
information from the region of the epiglottis and vallecula.
The spinal nucleus of CNV receives external ear and skull
base-meninges sensory information. Only the visceral motor
and sensory fibers from the dorsal vagal nucleus continue
on CNX to the rest of the body.
GRAPHIC, EXTRACRANIAL CNX
Axial graphic of nasopharyngeal carotid spaces shows the

extracranial vagus nerve situated posteriorly in the gap
between the internal carotid artery and the internal jugular
vein. Notice that at this level, CNIX, CNXI, and CNXII are all
still within the carotid space.
Axial graphic through the infrahyoid carotid spaces at the
level of the thyroid gland demonstrates the vagus trunk is
the only remaining cranial nerve within the carotid space. It
remains in the posterior gap between the common carotid
artery and the internal jugular vein. Note the recurrent
laryngeal nerve in the tracheoesophageal groove with the
visceral space. Remember the left recurrent laryngeal nerve
turns cephalad in the aortopulmonic window in the
mediastinum, whereas the right recurrent nerve turns at the
cervicothoracic junction around the subclavian artery.
AXIAL BONE CT
First of 3 axial bone CT images of the skull base presented
from superior to inferior is shown. The jugular foramen is
divided by the jugular spine into the anteromedial, smaller
pars nervosa, and posterolateral pars vascularis. The pars
vascularis transmits the vagus and accessory cranial
nerves, Arnold nerve, and jugular bulb, which becomes the
internal jugular vein.
In this image, the pars nervosa is seen to connect
anteromedially to the inferior petrosal sinus. CNIX, the
Jacobsen nerve, and the inferior petrosal sinus are all found
within the pars nervosa.
Image through the lower jugular foramen shows the sigmoid
sinuses emptying into the pars vascularis of the jugular
foramen. Notice the jugular foramen is located on the floor
of the posterior cranial fossa in the seam between the
petrous temporal bone anterolaterally and the occipital bone
posteromedially.
3T AXIAL T2 MR
First of 3 axial T2 MR images of the low brainstem
presented from superior to inferior is shown. The vagus
nerve is seen exiting the lateral medulla in the postolivary
sulcus inferior to the glossopharyngeal nerve.
In this image, the vagus nerve is clearly seen exiting the
postolivary sulcus into the lateral basal cistern bilaterally.
CNIX exits this sulcus just above the vagus nerve, while the
bulbar CNXI exits it just inferiorly.
At the level of the cephalad margin of the jugular foramen,
the bulbar root of the accessory nerve is seen exiting the
postolivary sulcus. The vagus nerve is entering the jugular
foramen laterally. Without thin-section-focused T2 imaging,
it is often difficult to separate the glossopharyngeal nerve,
vagus nerve, and bulbar root of the accessory nerve in the
basal cisterns.
3T MR
First of 3 axial slices of T2 sampling perfection with
(T2-SPACE) MR shows a section that includes the vagus
nerve along with partial views of the accessory and
glossopharyngeal nerves.
Second of 3 axial slices of T2-SPACE MR shows a detailed
view of 3D models obtained by manually segmenting each
of the vagus, glossopharyngeal, and accessory nerves,
which are shown in orange, green, and blue, respectively.
Third of 3 axial slices of T2-SPACE MR shows diffusion
tensor imaging (DTI) data overlaid on the T2-SPACE scan,
including a tractography reconstruction of the combination of
glossopharyngeal and vagus nerves. Also shown is a
background colormap of the principal tensor fiber
orientation, where red is left-right, green is anterior-
posterior, and blue is inferior-superior.
3T CORONAL T2-SPACE MR
First of 3 coronal slices of T2 sampling perfection with
(T2-SPACE) MR shows a section that includes the vagus
nerve alongside the glossopharyngeal nerve.
Second of 3 coronal slices of T2-SPACE MR shows a DTI
tractography reconstruction of the combination of
glossopharyngeal and vagus nerves in yellow.
Third of 3 coronal slices of T2-SPACE MR shows DTI
tractography reconstruction of the combination of
glossopharyngeal and vagus nerves in yellow. Shown in
gray is a 3D surface depicting the cistern, brainstem, and
vestibulocochlear nerve.
Accessory Nerve (CNXI)
Main Text
T ERM INOLOGY
Abbreviations
• Accessory nerve (CNXI)
Synonyms
• 11th cranial nerve (CN)
Definitions
• CNXI: Pure motor CN, supplying sternocleidomastoid,

trapezius muscles (through spinal component) and palatal,
pharyngeal, laryngeal muscles (through cranial component)
• Comment: There is some controversy regarding
fundamental anatomy of spinal accessory nerve; recently,
some authors have argued that nerves that arise from
caudal aspect of postolivary sulcus of medulla have variable
interaction with adjacent CNs; these fibers may join vagus
nerve directly
In some cases, these fibers remain as distinct nerves in
cistern, ultimately merging with vagus nerve in jugular
foramen or just below it to supply palate, larynx, and
pharynx; in this circumstance, bulbar (cranial)
components never actually merge with spinal
component of CNXI
IMAGING ANATOMY
Overview
• Motor cranial nerve only

• 4 CNXI segments are defined
Intraaxial, cisternal, skull base, and extracranial
Intraaxial Segment
• 2 distinct nuclear origins

Bulbar (cranial) motor fibers originate in lower nucleus
ambiguus (medulla)
– Fibers course anterolaterally to exit lateral medulla in
postolivary sulcus inferior to CNIX and CNX
Spinal motor fibers originate from spinal nucleus of
accessory nerve (spinal cord)
– Narrow column of cells along lateral aspect of
anterior horn cells from C1 to C5
– Nerve fibers emerge from lateral aspect of cervical
spinal cord between anterior and posterior roots
– Fibers combine forming bundle that ascends
entering skull base via foramen magnum
Cisternal Segment
• Bulbar portion travels anterolaterally through basal cistern

along similar course as CNIX and CNX
• Spinal portion enters lower lateral basal cistern, exits
thorough jugular foramen (JF)
• Bulbar root joins spinal component of accessory nerve
either in lower cistern or within JF
Skull Base Segment
• Passes through posterior pars vascularis of JF

Pars vascularis also contains vagus nerve (CNX) and
jugular bulb (and Arnold nerve)
Pars nervosa transmits glossopharyngeal nerve (CNIX),
Jacobson nerve, and inferior petrosal sinus
• Bulbar and spinal portions remain together in JF
• Fibers from bulbar portion, which arise within nucleus

ambiguus, separate from main nerve and merge with vagus
nerve in carotid space
Travel via CNX to supply muscles of palate, pharynx,
and larynx
– Palate : Levator veli palatini, palatoglossus,
palatopharyngeus, and musculus uvulae
– Pharynx : Superior constrictor and soft palate via
pharyngeal plexus
– Larynx : Except cricothyroid muscle via recurrent
laryngeal nerve
• Fibers from spinal portion remain in extracranial CNXI
Diverges posterolaterally from carotid space
Descend along medial aspect of sternocleidomastoid
muscle
Innervates sternomastoid muscle
Continues across floor of posterior cervical space in neck
Terminate in and innervate trapezius muscle


Superior sensitivity to skull base, meningeal, cisternal,
and brainstem pathology
Sequences should include combination of T2, T1 without
fat saturation, and contrast-enhanced T1 with fat
saturation in axial and coronal planes
• Bone CT used to supplement MR when complex skull base
pathology is present
Imaging Sweet Spots
• CNXI nuclei and intraaxial segment not directly visualized

• Cisternal segment is often not visualized on routine MR
imaging
High-resolution, thin-section T2 MR sequence usually
demonstrates CNIX, CNX, CNXI nerve complex passing
through basal cisterns from postolivary sulcus to pars
vascularis of JF
• Bone CT clearly demonstrates bony anatomy of pars
vascularis of JF
• Extracranial CNXI segment not directly visualized
Location inferred from its constant position deep to
sternocleidomastoid muscle in floor of posterior cervical
space
Imaging Pitfalls
• Hypertrophic levator scapulae muscle following serious

CNXI injury may mimic tumor
• Do not mistake this enlarged levator muscle for mass
Clinical Importance
• CNXI innervates sternocleidomastoid and trapezius muscles

• CNXI innervates sternocleidomastoid and trapezius muscles
• Essential for neck and shoulder movement, intrinsic larynx
motion
Function Dysfunction
• CNXI dysfunction: Isolated CNXI injury

Most common cause is radical neck dissection because
jugular nodal chain intimately associated with CNXI
Initial symptoms of spinal accessory neuropathy
– Downward and lateral rotation of scapula
– Shoulder droop resulting from loss of trapezius tone
Long-term findings in spinal accessory neuropathy
– Within 6 months, results in atrophy of ipsilateral
sternocleidomastoid and trapezius muscles
– Compensatory hypertrophy of ipsilateral levator
scapulae muscle occurs over months
• CNXI injury often occurs with injury of other lower cranial
nerves, particularly glossopharyngeal nerve (CNIX) and
vagus nerve (CNX)
Image Gallery
Print Images
GRAPHICS
Graphic of the posterior brainstem reveals both the spinal
and the bulbar roots of the accessory nerve (CNXI). Note
that the lower nucleus ambiguus gives rise to multiple
rootlets of the bulbar root of CNXI. Both the spinal and the
bulbar roots combine in the lateral basal cistern and jugular
foramen. The spinal root continues as extracranial CNXI to
innervate the sternocleidomastoid and trapezius muscles.
The bulbar root fibers cross to the vagus nerve
extracranially or within the jugular foramen to supply motor
innervation to the pharynx (superior constrictor and soft
palate) and the larynx (except the cricothyroid muscle).
Axial graphic shows the upper cervical spinal cord cut to
reveal the spinal nucleus of the accessory nerve giving rise
to multiple rootlets that unite to form the spinal root of the
accessory nerve. This includes cells along the lateral aspect
of the anterior horn from C1 to C5. The rootlets exit the
posterolateral sulcus just anterior to the posterior cervical
roots.
GRAPHIC, INTRACRANIAL AND EXTRACRANIAL

Overview graphic of the intracranial and extracranial
accessory nerve (CNXI) shows the lower nucleus ambiguus
at the origin of the bulbar root of CNXI while the spinal
nucleus gives rise to the spinal root. Both roots combine in
the jugular foramen. Extracranially, the bulbar fibers cross
to the vagus nerve to eventually provide motor innervation
via the pharyngeal plexus to the soft palate and superior
constrictor muscles and via the recurrent laryngeal nerve to
the majority of the endolaryngeal muscles. The spinal fibers
that remain in the accessory nerve provide motor
innervation to the sternocleidomastoid and trapezius
muscles. Notice extracranial CNXI runs in the floor of the
posterior cervical space.
AXIAL BONE CT AND 3T T2 MR
Axial bone CT through the jugular foramen shows the

anteromedial pars nervosa, the jugular spine, and the
posterolateral pars vascularis. The pars nervosa transmits
CNIX, the Jacobsen nerve, and the inferior petrosal sinus.
The pars vascularis transmits CNX, CNXI, the Arnold nerve,
and the sigmoid sinus, which becomes the internal jugular
vein.
Axial T2 MR at the level of the medulla shows the bulbar
portion of CNXI emerging from the postolivary sulcus just
inferior to CNX. The bulbar portion travels anterolaterally
through the basal cistern together with CNX and CNIX.
Axial T2 MR through the lower medulla reveals the spinal
root of CNXI climbing cephalad through the foramen
magnum to join the bulbar root of the CNXI before they
enter the pars nervosa of the jugular foramen. It is spinal
roots that eventually become the extracranial CNXI with
motor fibers to the sternocleidomastoid and trapezius
muscles.
Additional Images
Axial CECT of an 85-year-old woman with a large
paraganglioma of the right jugular foramen who presented
with multiple cranial neuropathies (IX-XII) at the level of the
hyoid bone shows intravascular tumor within the right
internal jugular vein . There is severe atrophy of the
trapezius and sternocleidomastoid muscles. There is
compensatory enlargement of the right levator scapulae
muscle , which can mimic a palpable mass on physical
exam.
Axial CT at the level of the thyrohyoid membrane in a 55-
year-old woman with chronic denervation injury to the right
spinal accessory nerve (that occurred during placement of
right ventriculoatrial shunt years earlier) demonstrates
marked atrophy of the trapezius and sternocleidomastoid
muscles. A catheter is noted in the right internal jugular
vein. There is mild hypertrophy of the right levator scapulae
muscle .
Hypoglossal Nerve (CNXII)
Main Text
T ERM INOLOGY
Abbreviations
• Hypoglossal nerve (CNXII)
Synonyms
Definitions
• CNXII: Motor nerve supplying intrinsic and extrinsic tongue

muscles
IMAGING ANATOMY
Overview
• Motor cranial nerve to intrinsic and extrinsic tongue muscles

Only extrinsic muscle not innervated by CNXII is
palatoglossus muscle (by CNX)
• Hypoglossal nerve anatomic segments
Intraaxial segment
Cisternal segment
Skull base segment
Extracranial segment
Intraaxial Segment
• Hypoglossal nucleus
In dorsal medulla between dorsal vagal nucleus and
midline
Long, thin nucleus that is approximately same length as
ventrolateral olive (15- to 18-mm craniocaudal
dimension)
Extends from level of hypoglossal eminence (trigone) in
floor of 4th ventricle just inferior to medullary striae of
4th ventricle to proximal medulla
In axial section, hypoglossal nucleus is located in dorsal
medulla, medial to dorsal vagal nucleus
• Hypoglossal intraaxial axonal course
Efferent fibers from hypoglossal nucleus extend ventrally
through medulla, lateral to medial lemniscus
Efferent fibers exit between olivary nucleus and pyramid
(root exit zone) at ventrolateral sulcus also called
preolivary sulcus
Cisternal Segment
• Efferent fibers coalesce to form multiple (6-14) rootlets

In premedullary cistern, course between posterior
inferior cerebellar artery and vertebral artery
• Rootlets fuse into hypoglossal nerve (2-4 trunks) just as it
exits skull base through hypoglossal canal
• Hypoglossal filaments may merge with vagal fibers
• Total length of cisternal segment ranges from 8-15 mm and
mean width from 0.3-0.6 mm
Skull Base Segment

• Hypoglossal nerve exits occipital bone via hypoglossal
canal, surrounded by venous plexus
Canal is in occipital bone caudal to jugular foramen
– "Empties" into medial nasopharyngeal carotid space
– Osseous septa may bisect hypoglossal canal
Mean length of hypoglossal canal reported to range from
9.5-16.0 mm and mean width from 1.3-3.0 mm
Variant anatomy of hypoglossal canal
– Osseous septa may bisect hypoglossal canal
– Rare persistent primitive hypoglossal artery arises
from cervical internal carotid artery C1-C2 level and
passes through hypoglossal canal into posterior
fossa; anastomoses with vertebrobasilar system
• Carotid space component of CNXII

Hypoglossal canal "empties" into medial nasopharyngeal
carotid space
Hypoglossal nerve immediately gives off dural branches
after exiting hypoglossal canal
Descends in posterior carotid space, closely apposed
with CNX
Exits carotid space anteriorly between jugular vein and
internal carotid artery, crosses lateral surface of external
carotid artery at inferior margin of posterior belly of
digastric muscle
• Transspatial component of CNXII
From carotid space, nerve runs anteroinferiorly toward
hyoid bone, lateral to carotid bifurcation
At level of occipital artery base, nerve turns anterior,
continuing as muscular branch below posterior belly of
digastric muscle, medial to submandibular gland
Gives off superior root of ansa cervicalis from horizontal
segment of nerve to anastomose with lower root
• Distal branches of imaging importance
Muscular branch travels on lateral margin of hyoglossus
muscle in posterior sublingual space close to lingual
artery, medial to mylohyoid muscle
– Innervates extrinsic (styloglossus, hyoglossus, and
genioglossus) and intrinsic tongue muscles
– Geniohyoid innervated by C1 spinal nerve
Ansa cervicalis : Formed from superior and inferior (C1-
C3 spinal nerves) roots; innervates infrahyoid strap
muscles (sternothyroid, sternohyoid, omohyoid)
• Direct CT or MR identification of CNXII in these spaces is
difficult, and position is inferred by adjacent anatomical
structures

• MR is preferred imaging study

Best for brainstem, cisterns, skull base, and suprahyoid
neck
Should include heavily T2-weighted sequence
• CECT with bone algorithm of skull base for skull base and
suprahyoid neck (cover from orbital roof to below hyoid)
Imaging Sweet Spots
• CT or MR evaluation requires entire coverage of nerve from

brainstem to hyoid bone
• Asymmetric appearance of tongue is clue to denervation
Acute/subacute: Denervated hemitongue may show T1
hypointensity and T2 hyperintensity and contrast
enhancement
Chronic: Tongue atrophy (fatty infiltration and volume
loss) on CT or MR; infrahyoid strap muscle atrophy
Infrahyoid strap muscles may also atrophy
Imaging Pitfalls
• Denervated hemitongue may appear enlarged due to edema

(acute) or flaccidity (chronic); may mimic infiltrative tongue
mass
• Not imaging hyoid bone will result in missed diagnoses
Clinical Importance
• Unilateral lesion causes tongue protrusion to "side of lesion"

• Nearly 50% of CNXII neuropathies are from neoplastic
processes, mostly malignant
Image Gallery
Print Images
GRAPHICS, INTRACRANIAL
Graphic of the lower brainstem seen from behind illustrates
key features of the proximal hypoglossal nerve. Notice the
hypoglossal nucleus in the dorsal paramedian medulla
feeding intraaxial axons that exit the preolivary sulcus into
the anterolateral basal cistern. Cisternal rootlets fuse into
the hypoglossal nerve that traverses the skull base through
the hypoglossal canal. Exiting the hypoglossal canal, CNXII
immediately enters the nasopharyngeal carotid space.
Axial graphic through the lower medulla shows the
hypoglossal nucleus feeding intraaxial axons that dive
ventrally to curve around the inferior olivary nucleus to exit
the medulla ventrolaterally via the preolivary sulcus. Note
that the hypoglossal nucleus gives the floor of the 4th
ventricle an arch (hypoglossal eminence/trigone). The
cisternal rootlets combine in the hypoglossal canal to
become the hypoglossal nerve (CNXII). Note the
hypoglossal canal is anterior and inferior to the jugular
foramen.
GRAPHIC, EXTRACRANIAL
Lateral graphic depicts the entire course of the hypoglossal
nerve. The nerve originates in the hypoglossal nucleus in the
floor of the 4th ventricle. As CNXII exits the skull base, it
immediately enters the nasopharyngeal carotid space just
medial to the internal carotid artery. It travels inferiorly in
the carotid space to exit anteriorly between the carotid
artery and the internal jugular vein. CNXII supplies motor
innervation to intrinsic and extrinsic (styloglossus,
hyoglossus, genioglossus) tongue muscles. C1 spinal nerve
supplies motor to the geniohyoid muscle. Ansa cervicalis
(C1-C3 spinal nerves) supplies motor innervation to the
infrahyoid strap muscles, including sternothyroid,
sternohyoid, and omohyoid muscles. Also note the
meningeal sensory branch from C1 following CNXII
retrograde to supply clival meninges.
AXIAL BONE CT AND 3T T2 MR
Axial bone CT at the level of the hypoglossal canal is

shown. Notice that the margins of the hypoglossal canals
are well corticated.
First of 2 axial T2 MR images through the lower medulla
demonstrates cisternal segment of hypoglossal nerves.
Anatomy of cisternal segment is variable, but usually,
multiple rootlets emerge from the preolivary sulcus and
merge into 2 trunks, which penetrate the dura to enter the
hypoglossal canal. The trunks abut or pass near the
vertebral arteries in the basal cisterns.
Hypoglossal nerves emerge from the medulla in the
preolivary sulcus between olive and pyramid. Cisternal
segment of the patient's left hypoglossal nerve is seen as a
thick, discrete trunk entering the hypoglossal canal. Right
hypoglossal nerve consists of multiple small rootlets.
CORONAL BONE CT
In the 1st of 3 coronal bone CT images presented from
posterior to anterior, the hypoglossal canal is seen as a
complete bony circle indicating the image is at the level of
the entry into the canal. The location of CNXII is in the
upper medial quadrant within the hypoglossal canal.
In this image of the midhypoglossal canal, the surrounding
bone appears as a bird's head and beak with the head and
beak made up of the jugular tubercle. The jugular foramen is
directly lateral to the hypoglossal canal.
At the level of the distal hypoglossal canal, the hypoglossal
nerve leaves the skull base to emerge inferiorly into the
nasopharyngeal carotid space. Notice the lateral jugular
foramen also empties its contents into the carotid space,
including the jugular vein and CNIX, CNX, and CNXI.
3T CORONAL T1 C+ MR
First of 3 sequential coronal T1 C+ MR images presented
from posterior to anterior is shown. In this MR, the
hypoglossal nerve is seen entering the proximal hypoglossal
canal. The hypointense hypoglossal nerve is surrounded by
strongly enhancing venous plexus and is therefore easily
seen on thin-section enhanced MR. The hypoglossal canal
also carries a branch of the ascending pharyngeal artery.
In this coronal MR of the midhypoglossal canal, the low-
signal hypoglossal nerve is visible surrounded by enhancing
venous plexus just beneath the "bird's beak" of the jugular
tubercle.
In this coronal image through the distal hypoglossal canal,
the hypoglossal nerves can be seen exiting inferolaterally
into the nasopharyngeal carotid space. Notice also the
internal jugular vein exiting inferiorly on the patient's right
into this same nasopharyngeal carotid space.
3T T2-SPACE MR
An axial slice of a T2 sampling perfection with application-
optimized contrasts by using flip angle evolution (T2-
SPACE) MR shows the cisternal segment of the
hypoglossal nerve.
A detailed axial view shows the cisternal segment of the
hypoglossal nerve. The nerve was manually segmented,
and 3D surface models are superimposed in red and
yellow.
Coronal slice of a T2-SPACE MR shows the cisternal
segment of the hypoglossal nerve. The nerve was manually
segmented, and 3D surface models are superimposed in
red and yellow.
3T MR TRACTOGRAPHY
A multimodal rendering of the hypoglossal nerve combines
T2-SPACE and diffusion tensor imaging data (DTI). The
background image shows both axial and coronal T2-SPACE
image slices, and a 3D surface of the cistern and brainstem
is shown in gray. A DTI tractography reconstruction of the
hypoglossal nerve is superimposed in green.
A view more closely aligned to an axial slice shows a DTI
tractography reconstruction of the hypoglossal nerve. Note
that the tracks terminate before turning toward the anterior
orientation of the nerve due to limitations in diffusion tensor
imaging acquisition.
A view from the right shows a sagittal T2-SPACE MR slice
and a DTI tractography reconstruction of the hypoglossal
nerve. Note that the tracks terminate before turning toward
the anterior orientation of the nerve due to limitations in
diffusion tensor imaging acquisition.
SECT ION 7
EXTRACRANIAL ARTERIES
Outline

Aortic Arch and Great Vessels
Main Text
T ERM INOLOGY
Abbreviations
• Aortic arch (AA); brachiocephalic trunk (BCT)

• Right common carotid arteries (RCCA)
• Left common carotid arteries (LCCA)
• Right subclavian arteries (RSCA)
• Left subclavian arteries (LSCA)
• Congenital heart disease (CHD)
Definitions
• Great vessels: Major vessels arising from AA (BCT, LCCA,

LSCA)
GROSS ANATOMY
Overview
• Thoracic aorta has 4 major segments (ascending aorta, AA,

aortic isthmus, descending aorta)
• Normal AA has 3 major branches (BCT, LCCA, LSCA)
IMAGING ANATOMY
Overview
• AA curves from right to left, slightly anterior to posterior in
superior mediastinum
• Anterior: Vagus nerve (CNX)

• Posterior
Trachea
Esophagus
Left recurrent laryngeal nerve
• Superior
Great vessels
Left brachiocephalic vein
• Inferior
Pulmonary trunk
Left recurrent laryngeal nerve
Branches
• BCT (innominate artery)

1st (largest) AA branch
Arises from superior convexity of AA
Ascends anterior to trachea
At sternoclavicular level, bifurcates into RSCA, RCCA
RSCA branches
– Internal thoracic (mammary) artery (courses
anteroinferiorly from RSCA)
– Right vertebral artery (courses superiorly from RSCA
just distal to RCCA origin)
– Thyrocervical trunk (gives off 2 major branches:
Inferior thyroid artery and its ascending cervical,
laryngeal and pharyngeal branches; suprascapular
artery)
– Costocervical trunk (gives off superior intercostal,
deep cervical arteries)
RCCA branches
– Bifurcates into internal carotid artery (ICA), external
carotid artery (ECA)
• Left common carotid artery
Arises from AA distal to BCT
Ascends in front of, then lateral to, trachea
Anteromedial to internal jugular vein
Branches into left ICA, ECA at level of upper thyroid
cartilage
• Left subclavian artery
Arises from AA just distal to LCCA
Ascends into neck, passing lateral to medial border of
anterior scalene
Crossed anteriorly by thoracic duct, left phrenic nerve
Branches
– Left internal thoracic (mammary) artery
– Left vertebral artery
– Left thyrocervical trunk
– Left costocervical trunk
Vascular Territory
• AA and great vessels supply neck, skull, entire brain
• Normal variants
Classic pattern with 3 branches seen in 80%
– 1st branch is BCT, followed by LCCA, LSCA
"Bovine" configuration (misnomer)
– Common origin of BCT, LCCA in 10-25%
LCCA arises from BCT in 5-7%
Left BCT (LCCA, LSCA share common origin) in 1-2%
Left VA arises directly from AA in 0.5-1%
Aortic "isthmus" (circumferential bulge beyond ductus)
may persist → aortic "spindle"
Ductus diverticulum (focal bulge along anteromedial
aspect of aortic isthmus), found in 9% of adults
• Anomalies
Left AA with aberrant RSCA
– Most common congenital arch anomaly (0.5-1%)
– 70%: RCCA, LCCA, LSCA, RSCA
– 25%: Common stem for RCCA/LCCA, LSCA, RSCA
– 5%: Other variations with RSCA as last branch from
AA
– ± aneurysmal dilation of RSCA ("ductus of
Kommerell")
Right AA with mirror image branching
– Left BCT, RCCA, RSCA
– 98% prevalence of CHD
Right AA with aberrant LSCA
– LCCA, RCCA, RSCA, LSCA
– 10% prevalence of CHD
– May form true vascular ring
Double AA (multiple variations)
– Most common vascular ring
– Right arch typically higher, larger than left
– Right arch usually gives origin to RSCA, RCCA; left
to LCCA, LSCA
– Rarely associated with CHD

• Left anterior oblique (LAO) position best visualizes AA,

great vessels
• CTA, contrast-enhanced MRA rival DSA in depicting AA,
great vessels
Image Gallery
Print Images
GRAPHICS
AP graphic shows the normal aortic arch (AA) and its

relationship to adjacent structures. The internal carotid
artery (ICA) usually arises from the common carotid artery
(CCA) posterolateral to the external carotid artery (ECA).
Skeletonized overview of the normal aortic arch is shown

with all other structures removed. The 3 major great vessels
[brachiocephalic trunk (BCT) (innominate artery), left
common carotid artery (LCCA), and left subclavian artery]
are depicted. The BCT and LCCA have a common V-
shaped origin together from the arch.
Four common aortic arch variants and anomalies are
depicted. Upper left: BCT and LCCA originate together from
aortic arch. Upper right: LCCA originates from BCT; only 2
vessels arise from AA. Lower left: Left vertebral artery (VA)
arises directly from AA. Lower right: Aberrant right
subclavian artery (RSCA) arises from arch as 4th great
vessel.
LEFT ANTERIOR OBLIQUE DSA

Early arterial phase DSA obtained in slight left anterior
oblique projection shows the AA and great vessels. The 1st
branch is normally the BCT (innominate artery), which
bifurcates into the right subclavian and right CCAs. The
LCCA, the 2nd major branch, typically originates very close
to (or sometimes from) the BCT. In this projection, the
origins of the left common carotid and subclavian arteries
slightly overlap.
Mid-arterial phase DSA shows the origin of the right VA. A
tiny inconstant branch, the thyroidea ima, arises from the
BCT.
Late arterial phase DSA shows the more distal branches of
the great vessels. The left VA is slightly larger than the right
VA. The thyroid gland is seen as a faint blush in between
the CCAs.
3D-VRT CECT
On 3D-VRT CT, AP projection, the major aortic arch
branches are clearly identified. The origin of the left VA is
seen. Note the 2 VAs as they course superiorly within the
transverse foramina of the cervical spine. Both carotid
bifurcations are at the C4-5 level, the most common
location.
The AA and carotid arteries are removed and the lateral
masses of C1 and C2 are cut away to show the VAs, which
ascend through the transverse foramina from C6 to C3. At
C2 they turn laterally in an inverted L shape, then ascend
toward the transverse foramina of C1. After they exit C1,
they course posteromedially around the atlantooccipital joint
above the ring of C1.
Cervical Carotid Arteries
Main Text
T ERM INOLOGY
Abbreviations
• Aortic arch (AA); brachiocephalic trunk (BCT)

• Common (CCA), internal (ICA), external (ECA) carotid
arteries
• Vertebral artery (VA), basilar artery (BA)
GROSS ANATOMY
Overview
• CCAs terminate by dividing into ECA, ICA

• ECA is smaller of 2 terminal branches
Supplies most of head, neck (except eye, brain)
Has numerous anastomoses with ICA, VA (may become
important source of collateral blood flow)
• ICA has no normal extracranial branches
IMAGING ANATOMY
Overview
• CCAs
Right CCA originates from BCT; left CCA from AA
Course superiorly in carotid space, anteromedial to
internal jugular vein
Divide into ECA, ICA at approximately C3-4 level
• Cervical ICAs
90% arise posterolateral to ECA
Carotid "bulb"
– Focal dilatation of ICA at its origin from CCA
– Flow reversal occurs in carotid bulb
Ascending cervical segment
– Courses superiorly within carotid space
– Enters carotid canal of skull base (petrous temporal
bone)
– No named branches in neck
• ECAs have 8 major branches
Superior thyroid artery
– 1st ECA branch (may arise from CCA bifurcation)
– Arises anteriorly, courses inferiorly to apex of
thyroid
– Supplies superior thyroid, larynx
– Anastomoses with inferior thyroid artery (branch of
thyrocervical trunk)
Ascending pharyngeal artery
– Arises from posterior ECA (or CCA bifurcation)
– Courses superiorly between ECA, ICA
– Visceral branches supply nasopharynx, oropharynx,
eustachian tube
– Muscular, tympanic branches supply middle ear,
prevertebral muscles
– Neuromeningeal branches supply dura, CNIX-CNXI
– Numerous important (potentially dangerous)
anastomoses with middle/accessory meningeal,
caroticotympanic, and vidian arteries!
Lingual artery
– 2nd anterior ECA branch
– Loops anteroinferiorly, then superiorly to tongue
– Major vascular supply to tongue, oral cavity,
submandibular gland
– Common origin with facial artery in 10-20% of cases
Facial artery
– Originates just above lingual artery
– Curves around mandible, then passes
anterosuperiorly across cheek
– Supplies face, palate, lip, cheek
– Anastomoses with ophthalmic artery (ICA branch),
other ECA branches
Occipital artery
– Originates from posterior aspect of ECA
– Courses posterosuperiorly between occiput and C1
– Supplies scalp, upper cervical musculature, posterior
fossa meninges
– Extensive anastomoses with muscular VA branches
Posterior auricular artery
– Arises from posterior ECA above occipital artery
– Courses superiorly to supply pinna, scalp, external
auditory canal, chorda tympani
Superficial temporal artery
– Smaller of 2 terminal ECA branches
– Runs superiorly behind mandibular condyle, across
zygoma
– Supplies scalp, gives off transverse facial artery
Maxillary artery
– Larger of 2 terminal ECA branches
– Arises within parotid gland, behind mandibular neck
– Gives off middle meningeal artery (supplies cranial
meninges)
– Runs anteromedially in masticator space
– Within pterygopalatine fossa sends off terminal
branches to deep face, nose
– Potential major source of collateral flow via
inferolateral trunk of cavernous ICA, ophthalmic
and recurrent meningeal arteries
• Cervical VAs
Originate from subclavian arteries, pass upward in
transverse foramina
Numerous muscular branches, ECA anastomoses
• Normal variants (common)

CCA bifurcation can be from T2 to C2
Medial (not lateral) origin of ICA from CCA in 10-15%
Arch origin of VA (5%)
• Anomalies (rare)
"Nonbifurcating" CCA
– No ICA bulb; ECA branches arise directly from CCA
– High association with aberrant course of ICA in
middle ear!
Persistent hypoglossal artery
– Second most common carotid-basilar anastomosis
– Arises from ICA at C1-2 level, passes through
hypoglossal canal to join BA
Proatlantal intersegmental artery
– Arises from cervical ICA at C2-3
– Connects cervical ICA with VA
Image Gallery
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GRAPHICS
Lateral graphic depicts common carotid artery (CCA) and
its two terminal branches, external and internal carotid
arteries (ECA, ICA). Scalp, superficial facial structures are
removed to show deep ECA branches. ECA terminates by
dividing into superficial temporal and internal maxillary
arteries (IMA). Within the pterygopalatine fossa, the IMA
divides into numerous deep branches. Its distal termination
is the sphenopalatine artery, which passes medially into the
nasal cavity. Numerous anastomoses between ECA
branches (e.g., between the facial and maxillary arteries) as
well as between the ECA and orbital and cavernous
branches of the ICA provide potential sources for collateral
blood flow.
Close-up view of the deep ECA branches and their
numerous anastomoses with branches from the ICA. The
maxillary artery terminal branches arise deep within the
pterygopalatine fossa.
LATERAL DSA: COMMON CAROTID ARTERY

Lateral unsubtracted DSA of a common carotid angiogram
shows the relationship of the CCA bifurcation to the cervical
spine and skull base. The typical CCA bifurcation is usually
around the C4-C5 level. The ICA normally arises posterior
and lateral to the ECA. All branches of the carotid arteries
below the skull base arise only from the ECA. The
pterygopalatine fossa, seen here behind the posterior
maxillary sinus wall, contains the terminal maxillary artery
division into its deep facial branches.
Early arterial phase of the CCA angiogram is shown with
bony structures subtracted. The major ECA branches are
opacified.
Late arterial phase shows opacification of the distal ECA
branches. The main terminal ECA branch is the maxillary
artery, shown here as it divides within the pterygopalatine
fossa.
OBLIQUE DSA: COMMON CAROTID ARTERY

Unsubtracted oblique view of a left common carotid DSA
shows the maxillary artery coursing toward its terminal
bifurcation within the pterygopalatine fossa. The ascending
pharyngeal artery is a small branch that is often obscured
by larger vessels on standard lateral views.
Subtracted view shows both proximal, distal branches of the
cervical ICA. Note that the ascending pharyngeal branch,
often not well seen on standard lateral or AP views, is well
visualized here as it courses superiorly toward the skull
base.
Late arterial phase shows the terminal maxillary artery
bifurcation within the pterygopalatine fossa. The superficial
temporal and middle meningeal arteries typically fill late on
common carotid angiograms.
3D-VRT CECT
Coned frontal 3D-VRT CECT image demonstrates the
cervical carotid arteries and their relationship to the cervical
spine. Here the CCA bifurcation is at the C4-C5 level, the
most common location. The external carotid arteries arise
anteromedial to the ICAs in ~ 90% of cases. Both the V1
(extraosseous) and V2 (foraminal) segments of both
vertebral arteries (VAs) can be seen ascending through the
transverse foramina from C6 to C2 in this view.
Right oblique 3D-VRT CECT image demonstrates the right
carotid bifurcation. The ICA initially ascends posterolateral
to the ECA but swings anteromedially as it courses
cephalad to the skull base. In this projection, the left ECA
and ICA are superimposed on each other.
Lateral view profiles the ICA bifurcations, right VA passing
into C6 transverse foramen.
3T MRA
MR angiogram of the cervical carotid and VAs profiles the
carotid bifurcation. The major ECA branches are well seen.
Oblique view shows the bifurcation. The distal loop of the
maxillary artery at its termination within the pterygopalatine
fossa can be seen here.
On this straight AP view, the carotid bifurcation is obscured
but distal ECA branches are well seen. The superficial
temporal artery has a characteristic tight "hairpin" turn as it
passes over the zygomatic arch.
LATERAL DSA: DISTAL EXTERNAL CAROTID ARTERY

Selective distal ECA angiogram, early arterial phase, lateral
view, shows the distal ECA and its main proximal branches.
The abrupt anterior angulation of the middle meningeal
artery as it passes intracranially through the foramen
spinosum is well demonstrated. Note "hairpin" turn of the
superficial temporal artery as it courses over the zygomatic
arch.
Midarterial phase shows the deep facial branches of the
ECA especially well. Most arise from the termination of the
maxillary artery within the pterygopalatine fossa, seen here
as a distinct loop just behind the maxillary sinus wall.
Late arterial phase shows very prominent vascular blushes
in mucosa of the sinuses, nose, orbit, and oropharynx. This
is a normal finding and should not be mistaken for vascular
malformation.
AP DSA: INTERNAL MAXILLARY ARTERY

Distal external carotid DSA, early arterial phase, AP view,
shows the termination of the maxillary artery as it loops
within the pterygopalatine fossa.
Midarterial phase shows the sphenopalatine artery, the
distal continuation of the maxillary artery, as it passes
medially through the sphenopalatine foramen into the nose.
Numerous small branches supply the vascular nasal
mucosa.
Late arterial phase shows a prominent vascular blush along
the nasal turbinates and palatal mucosa. Numerous small
nasal branches of the sphenopalatine artery ramify over the
conchae and meatuses and anastomose with branches of
the ethmoidal arteries and nasal branches of the greater
palatine artery. The sphenopalatine artery ends on the nasal
septum as posterior septal branches.
ULTRASOUND
M-mode ultrasound of normal carotid artery, longitudinal
image, shows normal wall thickness without evidence for
atherosclerosis. Three lines are seen in the carotid wall:
The white endoluminal line is the intimal reflection. The
darker line underneath represents the media. The thicker
peripheral white line is the adventitia.
Color Doppler ultrasound, longitudinal image, of normal
carotid bulb. Flow in the main lumen of the proximal ICA is
laminar. Note the area of disturbed/reversed flow in bulbous
portion of proximal ICA (mixed blue and red).
Power Doppler shows normal ECA with a proximal branch.
Color Doppler of right CCA with normal triphasic wave form.
The peak systolic velocity (PS) in this case is slightly high
for physiologic reasons.
Color Doppler of right ICA. Notice normal low-resistance
waveform. The PS of 61 cm/s is normal. Note that the CCA
waveform above shows higher resistance features (sharp
diastolic peak and little diastolic flow) as compared with the
internal carotid which has distinct low-resistance features
(broad systolic peaks, relatively large amount of diastolic
flow).
SECT ION 8
INTRACRANIAL ARTERIES
Outline

Intracranial Arteries Overview
Main Text
T ERM INOLOGY
Abbreviations
• Anterior, middle, posterior cerebral arteries (ACA, MCA,

PCA)
• Anterior, posterior communicating arteries (ACoA, PCoA)
• Basilar artery (BA)
• Vertebral artery (VA)
• Anterior, posterior inferior cerebellar arteries (AICA, PICA)
• Anterior choroidal artery (AChoA)
• Recurrent artery of Heubner (RAH)
GROSS ANATOMY
Anterior Circulation
• Internal carotid artery (ICA) and its branches + ACoA,

PCoA
Posterior Circulation
• BA and its branches
IMAGING ANATOMY
Overview
• ICA
Proximal to termination gives off ophthalmic artery,
AChoA, PCoA
Terminal bifurcation into ACA (smaller, medial), MCA
(larger, lateral)
ACA has 4 segments
– Horizontal or precommunicating (A1) segment
courses medially above optic chiasm, joined by
ACoA to contralateral A1
– Vertical or postcommunicating (A2) segment
courses superiorly in interhemispheric fissure,
around corpus callosum genu
– Distal (A3) segment courses posteriorly under
inferior free margin of falx cerebri, gives off cortical
branches
– Perforating arteries arise from A1, ACoA
– RAH arises from distal A1 or proximal A2
MCA has 4 segments
– Horizontal (M1) segment courses laterally to sylvian
fissure below anterior perforated substance, bi- or
trifurcates
– "Genu" or "knee" of MCA is gentle posterosuperior
turn toward lateral cerebral (sylvian) fissure
– Insular (M2) segments course within lateral cerebral
fissure, over insula
– Opercular (M3) segments begin at top of insula, turn
laterally in sylvian fissure to reach overhanging
frontal/parietal/temporal operculae
– Cortical (M4) branches emerge from lateral cerebral
fissure, course over hemispheric surface
– Perforating arteries arise from M1
• BA
Courses cephalad in prepontine cistern to terminal
bifurcation ventral to midbrain
– Gives off AICA, superior cerebellar arteries ( SCAs ),
pontine, midbrain perforating arteries
Bifurcates into PCAs, each of which has 4 segments
– Mesencephalic or precommunicating (P1) segment
lies within interpeduncular cistern, curves
posterolaterally from BA to PCoA junction
– Ambient (P2) segment extends from PCA-PCoA
junction, curving around cerebral peduncles just
above tentorium, above oculomotor nerve
– Quadrigeminal (P3) segment extends
posteromedially from level of quadrigeminal plate
– Cortical (P4) branches arise from distal PCA at or
just before reaching calcarine fissure
– Perforating branches arise from P1
VAs
– Intracranial (V4) segments enter dura near foramen
magnum
– Give off anterior/posterior spinal arteries, perforating
arteries to medulla, PICA
Vascular Territory
• Vascular distribution of ACA, MCA, PCA vary from

individual to individual, have typical as well as maximum,
minimum territories
• 2 vascular "watershed" zones exist at confluence of
territorial supply, are vulnerable to hypoperfusion
Cortical watershed = subpial confluence of cortical
ACA/MCA/PCA branches
Deep white matter watershed zone = confluence of deep
cortical penetrating branches, perforating branches from
circle of Willis (COW)
• ACA
Perforating branches: Corpus callosum rostrum, heads of
caudate nuclei, anterior commissure, anteromedial
putamen/globus pallidus/anterior limb internal capsule
(if RAH present)
RAH supplies caudate heads
Cortical branches: Inferomedial frontal lobes, anterior 2/3
of medial hemisphere surface, 1-2 cm over brain
convexity
• MCA
Perforating branches: Most of putamen, globus pallidus,
superior 1/2 of internal capsule, most of caudate
nucleus, some deep white matter
Cortical branches: Most of lateral surface of cerebral
hemispheres, anterior tip (pole) of temporal lobe
• PCA
Perforating branches: Much of central brain base
(thalamus, hypothalamus), midbrain, choroid plexus
Cortical branches: Most of inferior surface of temporal
lobe, occipital pole, variable amount of posterolateral
surface of hemisphere
• BA
All of PCA territory (including perforating branches),
most of pons, superior cerebellum/vermis
• VA
Most of medulla, cerebellar tonsils, inferior
vermis/cerebellar hemispheres

• Late arterial (capillary) phase of DSA with "brain stain"

shows vascular territory
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GRAPHIC AND 7T MRA
Graphic depicts the brain vascular system and its

relationship to the base of the brain. The anterior cerebral
arteries (ACAs) course cephalad in the interhemispheric
fissure from their junction at the anterior communicating
artery. They supply most of the medial brain surface except
for the posterior 1/3, which is supplied by the middle
cerebral artery (MCA). The MCA supplies most of the
lateral surface of the hemispheres. The posterior cerebral
artery (PCA) supplies most of the undersurface of the
temporal lobe except for its most anterior tip. The right
anterior and posterior inferior cerebellar arteries (AICA,
PICA) are shown on the right. On the left, a common AICA-
PICA trunk is present, a frequent normal variant.
Submentovertex view of a 7T MRA depicts normal

intracranial circulation. Compare with the previous graphic.
The visibility of both perforating and cortical branches of the
MCAs is significantly higher at ultrahigh field compared with
conventional imaging.
GRAPHICS
Typical vascular territories of the 3 major cerebral arteries

are depicted. The most common distribution of the ACA is
shown in green, as seen from lateral (upper left), medial
(upper right), from top down (lower left), and from the
submentovertex perspective (lower right). The ACA supplies
most of the medial hemispheric surface except for the
occipital lobe.
Usual vascular territory of the MCA is shown in red. The
MCA typically supplies most of the lateral and superior
surface of the hemisphere except for a small strip over the
vertex (ACA), occipital pole, and inferolateral temporal lobe
(PCA).
Usual vascular territory of the PCA is depicted in blue. The
PCA supplies the occipital poles and most of the
undersurface of the temporal lobe except for its tip, which is
usually supplied by the MCA.
The 3 major cerebral artery territories fit together like a
jigsaw puzzle as they supply the hemispheres. The ACA is
depicted in green. The MCA is shown in red. The PCA is
colored blue. The junction of territories forms the cortical
watershed zone. The posterior confluence where all 3
vascular distributions meet together, seen on the lower left
at the vertex, is especially vulnerable to cerebral
hypoperfusion.
Penetrating artery territories are shown in the axial plane.
PICA (tan) supplies the inferior cerebellum, lateral medulla.
The superior cerebellar artery is shown in yellow and the
AICA is shown in light blue. Medullary (aqua), pontine, and
thalamic perforating arteries (light purple) are derived from
the vertebrobasilar territory. Anterior choroidal (magenta),
lateral (medium blue), and medial (light green)
lenticulostriate arteries supply the basal ganglia, caudate,
and much of the corpus callosum.
Intracranial Internal Carotid Artery
Main Text
T ERM INOLOGY
Abbreviations
• Internal carotid artery (ICA)

• Ophthalmic artery (OA)
• Cavernous sinus (CS)
GROSS ANATOMY
Overview
• Complex course with several vertical/horizontal segments, 3

genus (1 petrous, 2 cavernous)
• 6 intracranial segments (cervical ICA = C1)
Petrous (C2), lacerum (C3), cavernous (C4)
Clinoid (C5), ophthalmic (C6), communicating (C7)
IMAGING ANATOMY
Segments, Branches
• Petrous (C2) segment

Contained within carotid canal of temporal bone
Surrounded by extensive sympathetic plexus
2 C2 subsegments joined at genu
– Short vertical segment [anterior to internal jugular
vein (IJV)]
– "Genu" (where petrous ICA turns anteromedially in
front of cochlea)
– Longer horizontal segment
Exits carotid canal at petrous apex
Branches
– Vidian artery (artery of pterygoid canal)
anastomoses with external carotid artery (ECA)
– Caroticotympanic artery (supplies middle ear)
• Lacerum (C3) segment
Small segment that extends from petrous apex above
foramen (f.) lacerum, curving upward toward CS
Covered by trigeminal ganglion
No branches
• Cavernous (C4) segment
3 subsegments joined by 2 genus (knees)
– Posterior vertical (ascending) portion
– Posterior (more medial) genu
– Horizontal segment
– Anterior (more lateral) genu
– Anterior vertical (subclinoid) segment
Covered by trigeminal ganglion posteriorly
Abducens nerve (CNVI) is inferolateral
Major branches
– Meningohypophyseal trunk (arises from posterior
genu, supplies pituitary, tentorium, and clival dura)
– Inferolateral trunk arises from horizontal segment,
supplies CS dura/cranial nerves; anastomoses with
ECA branches through f. rotundum, spinosum,
ovale
• Clinoid (C5) segment
Between proximal, distal dural rings of CS
Ends as ICA enters subarachnoid space near anterior
clinoid process
No important branches unless OA arises within CS
• Ophthalmic (C6) segment
Extends from distal dural ring at superior clinoid to just
below posterior communicating artery (PCoA) origin
2 important branches
– OA (originates from anterosuperior ICA, passes
through optic canal to orbit; gives off ocular,
lacrimal, muscular branches; extensive anastomoses
with ECA )
– Superior hypophyseal artery (courses
posteromedially; supplies anterior pituitary,
infundibulum, optic nerve/chiasm)
• Communicating (C7) segment
Extends from below PCoA to terminal ICA bifurcation
into anterior cerebral artery (ACA), middle cerebral
artery (MCA)
Passes between optic (CNII), oculomotor (CNIII) nerves
Major branches
– PCoA
– Anterior choroidal artery (courses posteromedial,
then turns superolateral in suprasellar cistern;
enters temporal horn at choroidal fissure; supplies
choroid plexus, medial temporal lobe, basal ganglia,
posteroinferior internal capsule)
• Petrous (C2) segment

Aberrant ICA (aICA)
– Presents as retrotympanic pulsatile mass; should not
be mistaken for glomus tympanicum tumor
– Absent vertical course; aICA courses more
posterolaterally than normal (appears as mass in
hypotympanum abutting cochlear promontory)
Persistent stapedial artery
– Arises from vertical segment, crosses cochlear
promontory and stapes footplate
– Enlarges tympanic segment of facial nerve canal
– Terminates as middle meningeal artery
– Seen as Y-shaped, enlarged geniculate fossa of
CNVII on CT
– Foramen spinosum is absent
• Cavernous (C4) segment
Persistent trigeminal artery
– Most common carotid-basilar anastomosis (0.02-
0.5%)
– Parallels course of CNV, passes posterolaterally
around (or through) dorsum sellae
– Connects ICA to vertebrobasilar (VB) system, forms
trident-shape on lateral DSA, sagittal MR
– May supply entire VB circulation distal to
anastomosis (Saltzman type I) or fill superior
cerebral arteries (SCAs) with posterior cerebral
arteries (PCAs) filled via patent PCoAs (Saltzman
type II)

Clinical
• Horner syndrome results from interruption of periarterial

sympathetic plexus around ICA (dissection, "bruising" of
plexus, etc.)
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GRAPHICS
The C3 (lacerum) internal carotid artery (ICA) segment is a
short segment that begins where the petrous carotid canal
ends. It passes above (not through) the foramen lacerum
and is covered by the trigeminal ganglion. Major branches
of the cavernous ICA (C4) segment are depicted with their
numerous anastomoses with external carotid artery (ECA)
branches (e.g., arteries of foramen ovale, rotundum).
There are numerous ICA to ECA anastomoses through
cavernous and deep facial branches of the 2 arteries,
respectively. A small artery, the vidian artery, is an
anastomosis between the internal maxillary artery (IMA)
and the petrous ICA segment. Numerous anastomoses in
and around the orbit are also present. The accessory
meningeal artery is a small but important branch that enters
the skull through the foramen ovale. It may supply part of
the trigeminal ganglion and anastomose with the
inferolateral trunk of the cavernous ICA.
LATERAL DSA
Lateral DSA of the left ICA in a patient with a dural
arteriovenous fistula (dAVF) of the left transverse sinus
demonstrates an enlarged tentorial marginal branch of the
meningohypophyseal trunk (MHT), which is also called the
posterior trunk.
Lateral DSA of the right ICA of the same patient
demonstrates a normal small meningohypophyseal artery. A
small inferolateral trunk is also visualized. There is transient
filling of the ipsilateral posterior cerebral artery via a
prominent posterior communicating artery. The approximate
location of exo- and endocranial openings of the petrous
carotid canal are shown.
Later arterial phase shows the normal vascular pituitary
"blush" adjacent to the posterior genu of the cavernous ICA.
The pituitary gland receives its arterial supply primarily by
cavernous branches of the ICA. Note the choroid plexus
"blush" from the anterior choroidal artery (AChoA).
OBLIQUE DSA
A series of 3 oblique views of a selective left internal carotid
DSA is shown. The early arterial phase demonstrates the
complex course of the ICA as it passes through the petrous
carotid canal and enters the cavernous sinus. The vertical
petrous ICA segment is much shorter than the horizontal
segment. The C3 (lacerum) segment is a short portion that
courses above the foramen lacerum between the
endocranial opening of the petrous carotid canal and the
petrolingual ligament.
Midarterial phase shows a small ophthalmic artery arising
from the ophthalmic (C6) ICA segment.
Late arterial phase shows the AChoA arising from the C6
(communicating) ICA segment. The AChoA arises medially,
coursing around the temporal lobe before it turns
posterolaterally toward the choroidal fissure.
AP DSA
A series of 3 AP views of a left internal carotid DSA is
illustrated. Early arterial phase shows the petrous and
cavernous ICA segments. The genu between the vertical
and horizontal petrous ICA segments is well seen. The
approximate endocranial opening of the petrous carotid
canal is indicated by the oval. The posterior and anterior
genus of the cavernous ICA are superimposed on this view.
The posterior ICA genu is slightly medial to the anterior
genu.
Midarterial phase shows the ophthalmic artery and AChoA.
Late arterial phase shows a faint "blush" of the choroid
plexus within the lateral ventricle.
3T MRA
MRA is excellent for depicting the intracranial ICA. Note on
this submentovertex reprojection that the posterior genu of
the cavernous ICA is more medial than its anterior genu.
The clinoid, ophthalmic, and supraclinoid (communicating)
ICA segments are all medial to the cavernous ICA.
Lateral view shows the cavernous ICA very well. Its small
branches are typically not well seen. The ophthalmic artery,
seen here as it originates from the anterosuperior surface
of the ICA, and the 2 major communicating segment
branches (posterior communicating artery and AChoA) are
well visualized.
Oblique view nicely shows the 3 knees or "genus" of the
intracranial ICA: The petrous genus and the posterior and
anterior genus of the ICA.
3D-VRT CTA
The 1st of 3 3D CTA volume-rendered images shows the
relationship between the distal ICA and the skull base. The
ICA pierces the dura at approximately the level of the
anterior clinoid process. The C5 (clinoid) segment lies
between the inner (proximal) and outer (distal) dural rings,
which are not well seen. The C6 (ophthalmic) segment
begins just above the optic canal, which is a good bony
landmark. The supraclinoid ICA is also called the
communicating (C7) segment. It gives rise to the posterior
communicating artery and the AChoA, as well as the ICA
distal bifurcation into the anterior and middle cerebral
arteries (ACA, MCA).
Oblique view shows the optic canal very well. The
ophthalmic artery is faintly seen here.
AP view shows the C7 (communicating or supraclinoid) ICA
segment and the terminal bifurcation into the ACA and
MCA.
CTA
Coronal MIP from a CTA shows the relationship of the
intracranial ICA to the anterior clinoid processes. The ICAs
pierce the dural ring medial to the anterior clinoid
processes. The terminal ICA bifurcation into the ACA and
MCA is well seen.
Section just slightly posterior to the previous level shows the
anterior genus of both cavernous ICAs, seen here as
contrast-enhanced, rounded densities within the cavernous
sinuses.
Axial MIP shows the terminal ICA bifurcations. Two small
posterior communicating arteries arise from the
communicating (C7) ICA segment.
Circle of Willis
Main Text
T ERM INOLOGY
Synonyms
• Circulus arteriosus
Definitions
• Central arterial anastomotic ring of brain
GROSS ANATOMY
Overview
• Circle of Willis (COW) is arterial polygon

• 10 components
2 internal carotid arteries (ICAs)
2 proximal or horizontal (A1) anterior cerebral artery
(ACA) segments
1 anterior communicating artery (ACoA)
2 posterior communicating arteries (PCoAs)
1 basilar artery (BA)
2 proximal or horizontal (P1) posterior cerebral artery
(PCA) segments
IMAGING ANATOMY
Overview
• Entire COW rarely seen on single DSA but completely

imaged on CTA/MRA
• COW lies above sella, in suprasellar cistern

• Surrounds ventral surface of diencephalon, inferolateral to
hypothalamus
• Horizontal (A1) ACA segments normally course above optic
nerves (CNII)
• PCoAs course below optic tracts, above oculomotor nerves
(CNIII)
Branches
• Important perforating branches arise from all parts of COW

• ACAs
Medial lenticulostriate arteries
Recurrent artery of Heubner
• ACoA
Unnamed perforating branches to anterior
hypothalamus, optic chiasm, cingulate gyrus, corpus
callosum, and fornix
Occasionally, large vessel, median artery of corpus
callosum, arises from ACoA
• PCoA
Anterior thalamoperforating arteries
• BA, PCAs
Posterior thalamoperforating arteries
Thalamogeniculate arteries
Vascular Territory
• Entire central base of brain (including hypothalamus,
internal capsule, optic tracts, thalamus, midbrain)
• Variation is rule, not exception!

Absent/hypoplastic components (60%)
Hypoplastic/absent PCoA (25-33%)
Hypoplastic/absent A1 (10-20%)
"Fetal" origin of PCA from ICA (15-25%)
– PCoA is same diameter as ipsilateral PCA
– P1 is hypoplastic/absent
Absent, duplicate, or multichanneled ACoA (10-15%)
Junctional dilatation ("infundibulum") at PCoA origin
from ICA (5-15%)
– Should be 2 mm or less
– Funnel-shaped, conical
– PCoA arises from apex
• True anomalies rare
ACA-ACoA complex
– Infraoptic origin of ACA
Associated with ↑ prevalence of aneurysms
– Single (azygous) ACA
↑ prevalence of aneurysms
Common in holoprosencephalies
PCoA-PCA-BA complex
– Persistent carotid-basilar anastomoses
Persistent trigeminal artery (most common)
Persistent hypoglossal artery (2nd most
common)
Persistent otic artery (very rare)
Proatlantal (intersegmental) artery

Questions
• COW provides major source of collateral blood flow to brain

If any segment is hypoplastic or absent
– Potential for collateral flow in case of large vessel
occlusion may be severely limited
• CTA/MRA best for imaging entire COW

• DSA requires multiple views ± cross compression of
contralateral carotid artery to visualize ACoA
Imaging Pitfalls
• Absent COW segment usually congenital

• If PCA not visualized at vertebral angiography, anatomic
variant with ICA ("fetal") origin more likely than occlusion
EMBRYOLOGY
Embryologic Events
• ICAs develop from 3rd aortic arches, dorsal aortae, vascular

plexus around forebrain
• Embryonic ICAs divide into cranial, caudal divisions
Cranial divisions give rise to
– Primitive olfactory, anterior/middle cerebral, anterior
choroidal arteries
– ACoA forms from coalescence of midline plexiform
network, connects developing ACAs
Caudal divisions
– Become PCoAs
– Supply stems (proximal segments) of PCAs
• Paired dorsal longitudinal neural arteries fuse, form BA
• Developing vertebrobasilar circulation usually incorporates
PCAs
• Caudal ICA divisions regress, form PCoAs
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GRAPHICS AND 3D CTA
Schematic rendering of the circle of Willis (COW) as seen

from below is shown. All components are present, but their
size and configuration vary widely. Absence or hypoplasia
of 1 or more segments is the rule, not the exception.
The COW and its relationship to adjacent structures is

depicted. The COW is located in the suprasellar cistern just
below the diencephalon. The hypothalamus, infundibular
stalk, and optic chiasm lie in the middle of the COW. The
horizontal (A1) anterior cerebral artery (ACA) segment
passes above the optic nerves (CNII); the posterior
communicating artery (PCoA) passes above the oculomotor
nerves (CNIII). The anterior communicating artery (ACoA) is
near the midline, below the interhemispheric fissure.
Patient-specific 3D CTA segmented by Drs. Adriene

Eastaway, Michael Bayona, Edward Quigley, edited in
Materialise Mimics, Materialise 3-matic, Microsoft 3D
Builder, Sketchfab Viewer using subsurface lighting,
transparency of the calvarium, opacity of the sphenoid, and
occiput for orientation. Presented at ASNR Vancouver,
2018.
7T MRA
Submentovertex view from a high-resolution MR angiogram

obtained at 7T is depicted for comparison with the previous
graphic and 3D CTA. In this case, all segments of the COW
are present, a so-called "balanced" COW in which no
segment is absent or hypoplastic.
AP section through the pituitary gland, suprasellar cistern
(MIP reconstruction) from 7T MRA is shown. In this view,
the supraclinoid internal carotid arteries (ICAs), their
bifurcations, and horizontal (A1) ACA segments of COW
are especially well seen. Lenticulostriate arteries originating
from middle cerebral artery (MCA) and vertical (A2) ACA
segments are visible as well.
Oblique view of a right internal carotid MRA obtained at 7T
shows the horizontal (A1) ACA segment and profiles the
ACoA especially well. The vertical or postcommunicating
(A2) ACA segments are also well seen, as is the ICA
bifurcation. The MCA, which is not part of the COW, is also
nicely visualized in this projection. This is an excellent
projection for evaluation of the ACoA and MCA for the
presence of an intracranial aneurysm.
DSA
Lateral view of DSA from an internal carotid angiogram
shows the normal relationship of the PCoA to the ICA and
posterior cerebral artery (PCA). Here, the PCA fills
transiently from the ICA injection.
Lateral view from a DSA of a selective internal carotid
angiogram shows a so-called fetal origin of the PCA from
the ICA. Here, the PCoA is large and continues posteriorly
as the PCA. The vertebrobasilar study in this patient (not
shown) had no filling of the ipsilateral PCA, as the
precommunicating (P1) segment was congenitally absent.
Lateral view of a vertebrobasilar DSA shows contrast
refluxing into a PCoA. Perforating branches from the PCoA
and proximal PCAs are especially well seen in this study.
Additional Images
High-resolution CTA is shown with the brain removed. The
relationship of the COW and adjacent bony structures is
well seen. The COW lies above the sella turcica, within the
suprasellar cistern. The ACoA is obscured in this view by
overlap of the postcommunicating vertical (A2) ACA
segments.
Close-up view delineates the distal bifurcation of the left
ICA into a smaller medial branch (the horizontal or A1 ACA
segment), and a larger lateral branch (the middle cerebral
artery) is especially well seen here.
Oblique view of the CTA as seen from above shows the
relationship of the basilar artery and distal bifurcation to the
clivus and dorsum sellae.
Anterior Cerebral Artery
Main Text
T ERM INOLOGY
Abbreviations
• Anterior cerebral artery (ACA)
GROSS ANATOMY
Overview
• Smaller, more medial terminal branch of

supraclinoid internal carotid artery (ICA)
• 3 segments
Horizontal or precommunicating ( A1 ) segment
Vertical or postcommunicating ( A2 ) segment
Distal ( A3 ) segment and cortical branches
• Anterior communicating artery (ACoA) connects right, left
A1 segments
IMAGING ANATOMY
Overview
• ACA excellent midline marker

• Displacement from midline common with space-occupying
lesions or hemisphere atrophy
• A1 : Extends medially over optic chiasm/nerves

• A2 : Runs superiorly in interhemispheric fissure, anterior to
corpus callosum rostrum
• A3 : Curves around corpus callosum genu, divides into
pericallosal, callosomarginal arteries
Pericallosal artery arises from A2 near corpus callosum
genu
– Larger of 2 major distal ACA branches
– Courses posterosuperiorly above corpus callosum,
below cingulate gyrus
– Continues around corpus callosum splenium
Callosomarginal artery
– Smaller of 2 distal ACA branches
– Courses posterosuperiorly in cingulate sulcus, above
cingulate gyrus
• A4 : Most cortical arteries arise from pericallosal artery
Branches
• Cortical branches (8 branches, named according to territory

they supply)
Orbitofrontal artery
– 1st cortical branch of ACA
– Arises from proximal A2 or pericallosal artery
– Ramifies over gyrus rectus, inferior surface of frontal
lobe
Frontopolar artery
– Arises from pericallosal artery or callosomarginal
trunk opposite corpus callosum genu
– Extends anteriorly to frontal pole
Anterior, middle, posterior internal frontal arteries
– Supply medial surface of superior frontal gyrus
Paracentral artery
– Usually small, supplies paracentral lobule
Superior, inferior internal parietal arteries
– Supply precuneus
– In no instances does ACA branch cross parieto-
occipital fissure to supply occipital lobe
• Perforating branches (arise from A1 or ACoA)
Medial lenticulostriate arteries
– Arise from A1, ACoA; course superiorly through
anterior perforated substance
Recurrent artery of Heubner
– Arises from distal A1 or proximal A2
– Curves back laterally above A1 to enter anterior
perforated substance and supply caudate head
Vascular Territory
• Cortical branches supply anterior 2/3 of medial hemispheres,

convexity
• Penetrating branches supply medial basal ganglia, corpus
callosum genu, anterior limb of internal capsule
• Normal variants: Most common = hypoplastic/absent A1

ACoA can be absent, fenestrated, duplicated
"Bihemispheric ACA" (distal ACA branches supply part
of contralateral hemisphere)
"Triplicate" A2s (if embryonic median artery of corpus
callosum persists)
• Anomalies (rare)
"Azygous" ACA (typically associated with
holoprosencephaly)
– Single ACA arises from junction of both A1s
– ACoA absent
Infraoptic ACA
– A1 passes under (not over) optic nerve
– High prevalence of intracranial aneurysms

• Multiple views/multiplanar reconstruction required to

profile ACoA
• May need to compress contralateral carotid artery during
DSA to force contrast across ACoA
Imaging Pitfalls
• Lack of ACA filling on injection of ipsilateral carotid artery

usually caused by absent/hypoplastic A1 (both ACA
territories fill from ICA)
• Rotation of head off midline causes ACA to appear
displaced on AP DSA
Clinical Importance
• ACoA is common site for aneurysm formation

• ACA occlusion much less common than middle, posterior
cerebral artery involvement
• Distal ACA occlusion may occur with severe subfalcine
herniation of cingulate gyrus
EMBRYOLOGY
Embryologic Events
• 5 weeks: Primitive ACAs appear, extend toward midline
• 6 weeks: Plexiform anastomosis forms, normally regresses to
form definitive ACoA
• 7 weeks: Definitive ACAs formed
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GRAPHICS
Submentovertex view shows the relationship of the circle of

Willis and its components to the cranial nerves. Note that
the normal course of the horizontal (A1) segment is over the
optic nerves.
Sagittal (midline) graphic through the interhemispheric

fissure shows the relationship of the anterior cerebral artery
(ACA) and its branches to the underlying brain parenchyma.
The A2 segment ascends in front of the 3rd ventricle within
the cistern of the lamina terminalis. The A3 segment curves
around the corpus callosum genu. The branch point of the
distal ACA into the pericallosal and callosomarginal arteries
varies. Almost the entire anterior 2/3 of the medial
hemisphere surface is supplied by the ACA and its
branches. Branches of the posterior and anterior cerebral
arteries anastomose around the corpus callosum genu.
LATERAL DSA
Digital subtraction internal carotid angiogram, lateral view,

midarterial phase, shows the ACA and its major cortical
branches.
Late arterial phase, lateral view, shows the vascular plexi
that delineate both the ocular choroid (supplied by branches
of the ophthalmic artery) and the superior surface of the
corpus callosum (the so-called pericallosal pial "blush").
AP DSA
Digital subtraction right internal carotid angiogram, AP view,
midarterial phase, shows the ACA and its branches. Both
distal ACAs fill from this injection because contrast has
refluxed across the anterior communicating artery (which is
not well seen on this projection). Note the ACAs are
generally positioned in the midline, although they "wander"
across the midline somewhat. This angiographic
appearance is normal.
Late arterial phase, AP view from the same series, shows
the typical vascular "blush" formed by small branches of the
pericallosal arteries as they course over the superior
surface of the corpus callosum. Note that in this case, distal
branches of both ACAs were filled when the right internal
carotid artery was injected. The right middle meningeal
artery is opacified because it originated from the ophthalmic
artery, a normal variant seen in ~ 0.5% of cases.
3T MRA
Submentovertex view from 3D TOF MRA shows the right
internal carotid artery and its branches. The major branches
of the ACA are well seen, although smaller branches (such
as the medial lenticulostriate arteries and recurrent artery of
Heubner) are not well delineated.
Lateral view of MRA demonstrates both ACAs and their
major branches.
Slightly oblique AP view of the right internal carotid artery
circulation shows the ACA and anterior communicating
artery, which is especially well seen. Short perforating
branches are not visualized.
CTA
Axial 3D color volume rendering of the circle of Willis
obtained using 64 detector row CT angiography is shown.
Both horizontal (A1) ACA segments are symmetric. The
anterior communicating artery is hypoplastic and not well
seen on this view. The A2 (vertical) segment of both
arteries within the interhemispheric fissure are seen in the
midline.
Sagittal midline MIP image from the same series clearly
delineates both A2 segments as they course superiorly
within the interhemispheric fissure in the cistern of the
lamina terminalis. The corpus callosum genu can be faintly
seen in this section, as well as CSF within the lateral
ventricle.
AP MIP section shows both horizontal (A1) ACA segments.
Note the hypoplastic anterior communicating artery oriented
in a near-vertical plane. The anterior communicating artery
course and configuration vary widely from patient to patient.
Middle Cerebral Artery
Main Text
T ERM INOLOGY
Abbreviations
• Middle cerebral artery (MCA)
Synonyms
• Sylvian (lateral cerebral) fissure

• Insula (island of Reil)
Definitions
• Opercula = parts of frontal, parietal, and temporal lobes that

"overhang" and "enclose" sylvian fissure
GROSS ANATOMY
Overview
• Larger, lateral terminal branch of supraclinoid internal

carotid artery (ICA)
• 4 segments
Horizontal (M1) segment
Insular (M2) segments
Opercular (M3) segments
Cortical branches (M4) segments
IMAGING ANATOMY
Overview
• M2, M3 branches delineate insula, sylvian fissure
• Horizontal (M1) segment

Extends from terminal ICA bifurcation to sylvian fissure
Lies lateral to optic chiasm, behind olfactory trigone
Courses laterally under anterior perforated substance
Usually bi- or trifurcates just before sylvian fissure
Postbifurcation trunks enter sylvian fissure then turn
upwards in gentle curve (MCA "genu")
• Insular (M2) segments
6-8 "stem" arteries arise from postbifurcation trunks,
course superiorly within sylvian fissure, ramify over
surface of insula
M2 segments end at top of sylvian fissure
• Opercular (M3) segments
M3 segments begin at top of sylvian fissure, course
inferolaterally through sylvian fissure
Exit sylvian fissure at surface of brain
• Cortical (M4) segments
Exit sylvian fissure and ramify over lateral surface of
hemisphere
Branches
• Perforating branches (lenticulostriate arteries), anterior

temporal artery arise from M1
• Cortical branches (M4 segments)
Orbitofrontal (lateral frontobasal) artery
Prefrontal arteries
Precentral (prerolandic) artery
– Runs between precentral and central sulci
Central sulcus (rolandic) artery
– Runs within central (rolandic) sulcus
Postcentral sulcus (anterior parietal) artery
– Runs in postcentral, then intraparietal sulcus
Posterior parietal artery
– Exits posterior end of sylvian fissure
– Runs posterosuperiorly along supramarginal gyrus
Angular artery
– Most posterior branch exiting sylvian fissure
– Runs posterosuperiorly over transverse temporal
gyrus
Temporooccipital artery
– Runs posteroinferiorly in superior temporal sulcus
Posterior temporal, medial temporal arteries
– Extend inferiorly from sylvian fissure
– Cross superior, middle temporal gyri
Vascular Territory
• Cortical branches
Considerable variation in territory of individual branches
Most common pattern
– Supply most of lateral surface of cerebral
hemispheres except for convexity and inferior
temporal gyrus
– Anterior tip of temporal lobe (variable)
• Penetrating branches
Medial lenticulostriate arteries (few arise from proximal
MCA)
– Medial basal ganglia, caudate nucleus
– Internal capsule
Lateral lenticulostriate arteries
– Lateral putamen, caudate nucleus
– External capsule
• High variability in branching patterns

"Early" MCA bi- or trifurcation (within 1 cm of origin)
• True anomalies (hypoplasia, aplasia) rare
MCA duplication seen in 1-3% of cases
– Large branch arises from distal ICA just prior to
terminal bifurcation
– Parallels main M1
Accessory MCA (rare)
– Arises from anterior cerebral artery
– High association with saccular aneurysm
Fenestrated MCA (rare)
EMBRYOLOGY
Embryologic Events
• Definitive appearance of MCA intimately related to

formation of sylvian fissure, insula
• Fetal brain initially smooth, unsulcated; MCA branches lie
over surface
• Shallow depressions on both sides of developing
hemispheres appear at 8-12 weeks gestation
• Depressions deepen, become overlapped by edges
(opercula) of developing frontal, parietal, temporal lobes
MCA branches follow depressions, infolding brain
• Sylvian fissure forms, insula within its depths
• MCA branches curve up/over insula, then turn laterally, exit
sylvian fissure, ramify over brain surface
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GRAPHICS
The middle cerebral artery (MCA) and its relationship to

adjacent structures is depicted on these graphics.
Submentovertex view with the left temporal lobe sectioned
through the temporal horn of the lateral ventricle is
illustrated. The MCA supplies much of the lateral surface of
the brain and is the larger of the 2 terminal branches of the
internal carotid artery (ICA).
AP view shows the MCA and its relationship to the adjacent

brain. The MCA course through the sylvian fissure and the
M1-M4 segments are well delineated. A few medial and
numerous lateral lenticulostriate arteries arise from the top
of the horizontal (M1) MCA segment, course superiorly
through the anterior perforated substance, and supply the
lateral basal ganglia + external capsule.
LATERAL DSA
Three lateral views of a left internal carotid angiogram show

the MCA, beginning with early arterial phase. Filling of the
insular (M2) segments delineates the insula (sylvian
"triangle").
Midarterial phase shows filling of the opercular (M3) and
cortical (M4) MCA segments. Transient filling of the
ipsilateral posterior cerebral artery via the circle of Willis
has occurred.
Late arterial phase shows filling of the distal MCA branches
with "brain stain" (diffuse vascular "blush") of the cortex.
Note that only the most anterior aspect of the temporal lobe
is opacified. Most of the temporal lobe is supplied by the
posterior cerebral artery.
AP DSA
Three AP views of left internal carotid angiogram illustrate
normal MCA angiographic anatomy. Only the horizontal
(M1) and insular (M2) segments are filled out on this early
arterial phase image. The MCA bifurcates within 1 cm of its
origin, a so-called "early bifurcating" MCA. The angiographic
"sylvian point" is the highest, most medial insular loop of the
MCA.
Midarterial phase demonstrates the insular (M2) and
opercular (M3) MCA segments as well as early filling of
some cortical (M4) MCA branches.
Late arterial phase shows contrast has been washed out of
the more proximal (M1, M2) MCA segments. The distal
cortical (M4) MCA branches are now completely opacified.
Note the "brain stain" caused by opacification of small
branches within the basal ganglia as well as the cortex.
3T MRA
Three views of 3T MR angiogram are shown from top to
bottom. Lateral view is shown on top.
AP view of the MR angiogram shows the MCA and its
branches. The lateral lenticulostriate arteries are barely
seen.
Submentovertex view is optimal for visualizing the MCA bi-
or trifurcation (genu) and the opercular (M3) segments.
MCA aneurysms are often best delineated in this projection.
3D-VRT CTA
Patient-specific 3D CT angiography was performed for
basilar tip aneurysm segmented by Drs. Adriene Eastaway,
Michael Bayona, and Edward Quigley. This was segmented
in Materialise Mimics and edited in Materialise 3-matics,
Microsoft 3D Builder, Sketchfab Viewer using subsurface
lighting, with transparency of upper calvarium, and opaque
of the skull base for orientation. The right horizontal (M1)
MCA is laid out and the MCA bifurcation into its anterior and
posterior M2 trunks are clearly delineated.
CTA
Three axial MIP views from a high-resolution CTA delineate
the MCA and its branches. The lowest image, seen here,
locates the MCA bifurcation precisely and shows the M1
segment especially well.
Section slightly above the top image shows the insular (M2)
MCA segments, especially well seen on the left.
Section through the foramen of Monro shows the opercular
(M3) MCA segments bilaterally.
Three coronal (AP) MIP images from CT angiogram
demonstrate the lenticulostriate arteries especially well. CT
angiogram through the bifurcation of the internal carotid
arteries is shown.
Slightly more anterior view shows origins of 2 prominent
lenticulostriate arteries. The MCA gives rise to a few medial
lenticulostriate arteries (most arise from the horizontal or A1
anterior cerebral artery segment). The more numerous
group of perforating arteries, the lateral lenticulostriate
arteries, arises from the mid and distal M1 segments, and
passes cephalad through the anterior perforated substance
into the lateral basal ganglia and external capsule.
Most anterior view shows the A2 segments of both anterior
cerebral arteries as well as opercular (M3) MCA branches
on the right and an insular (M2) segment on the left. Apex of
insular loops marks the top of the insula.
Posterior Cerebral Artery
Main Text
T ERM INOLOGY
Abbreviations
• Posterior cerebral artery (PCA)

• Posterior communicating artery (PCoA)
• Basilar artery (BA)
GROSS ANATOMY
Overview
• Main BA terminal branches = 2 PCAs

• 4 segments
Precommunicating (P1 or mesencephalic) segment
Ambient (P2) segment
Quadrigeminal (P3) segment
Calcarine (P4) segment
• PCoAs connect PCA to ICA at P1/P2 junction
IMAGING ANATOMY
Overview
• PCAs sweep posterolaterally around midbrain

• P1 (precommunicating) segment
Extends laterally from BA bifurcation to junction with
PCoA
Courses above cisternal segment of oculomotor nerve
(CNIII)
• P2 (ambient) segment
Extends from P1/PCoA junction
Curves around cerebral peduncle within ambient
(perimesencephalic) cistern
Lies above tentorium, cisternal segment of trochlear
nerve (CNIV)
Parallels optic tract, basal vein of Rosenthal
• P3 (quadrigeminal segment)
Short segment within quadrigeminal cistern
Extends behind midbrain (quadrigeminal plate level) to
calcarine fissure (occipital lobe)
• P4 (calcarine) segment
PCA terminates above tentorium, in calcarine fissure
Branches
• Perforating (central) branches

Posterior thalamoperforating arteries
– Arise from P1, pass posterosuperiorly in
interpeduncular fossa
– Enter undersurface of midbrain
Thalamogeniculate arteries
– Arise from P2, pass posteromedially into midbrain
Peduncular perforating arteries arise from P2, pass
directly into cerebral peduncles
• Ventricular/choroidal branches (arise from P2)
Medial posterior choroidal artery
– Curves around brainstem, enters tela choroidea, and
runs anteriorly along roof of 3rd ventricle
Lateral posterior choroidal arteries
– In lateral ventricle choroid plexus, curves anteriorly
around thalamus
• Cortical branches
Anterior temporal artery arises from P2, courses
anterolaterally under parahippocampal gyrus of inferior
temporal lobe
Posterior temporal artery arises from P2, courses
posteriorly
Distal PCA divides into 2 terminal trunks
– Medial branches: Medial occipital artery,
parietooccipital artery, calcarine artery, posterior
splenial arteries
– Lateral branches: Lateral occipital artery, temporal
arteries
Vascular Territory
• Penetrating branches: Midbrain, thalami, posterior limb of

internal capsule, optic tract
• Ventricular/choroidal branches: Choroid plexus of
3rd/lateral ventricles, parts of thalami, posterior
commissure, cerebral peduncles
• Splenial branches: Posterior body and splenium of corpus
callosum
• Cortical branches: Posterior 1/3 of medial hemisphere
surface; most of inferior temporal lobe, most of occipital lobe
(including visual cortex)
• "Fetal" origin of PCA

Large PCoA gives direct origin to PCA
P1 (precommunicating) PCA segment hypoplastic or
absent
• Persistent carotid-basilar anastomoses
PCAs supplied by persistent trigeminal artery or
proatlantal intersegmental artery

Imaging Pitfalls
• Absent PCA on vertebral angiogram usually due to "fetal"

origin, not occlusion
Injection of ipsilateral carotid artery confirms presence of
"fetal" PCA
Clinical Importance
• PCA occlusion causes homonymous hemianopsia
EMBRYOLOGY
Embryologic Events
• Definitive PCAs develop later than anterior, middle cerebral

arteries
• Circulation to fetal cerebral hemispheres initially supplied
entirely by embryonic ICA
• Proximal PCAs sprout from caudal division of embryonic
ICA
• Vertebral, basilar arteries form from fusion of dorsal
longitudinal neural arteries
• Anastomose with sprouting PCA stems
• Distal PCAs sprout from proximal stems
Image Gallery
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GRAPHICS
Lateral graphic depicts the posterior cerebral artery (PCA)

and its branches. The tentorium and CNIII lie between the
PCA above and the superior cerebellar artery below. The
PCA has central (perforating), choroidal, and cortical
branches as well as a small branch to the corpus callosum
splenium.
Submentovertex graphic shows the PCA and the

relationship of its segments to the midbrain. The PCA
supplies the occipital lobe and almost all of the inferior
surface of the temporal lobe (except for its tip). The
precommunicating (P1) PCA segment extends from the
basilar bifurcation to the posterior communicating artery
(PCoA) junction. The ambient (P2) segment swings
posterolaterally around the midbrain. The quadrigeminal
segment (P3) lies behind the midbrain. The PCA terminal
segment is the calcarine (P4) segment.
LATERAL VA DSA
Series of 3 lateral views from a vertebrobasilar angiogram

shows the PCA and its branches. Early arterial phase
shows contrast reflux into the ipsilateral PCoA. Both
anterior and posterior thalamoperforating arteries are
opacified. The lateral posterior choroidal artery has a
prominent "3" shape that allows it to be identified easily on
this projection. The precommunicating (P1) PCA segment is
not well seen, but the P2 segment is shown as it curves
around and behind the midbrain.
Midarterial phase shows the posterior thalamoperforating

and choroidal arteries especially well. Note that PCA
cortical branches are supplying the posterior 1/3 of the
medial hemisphere surface.
"Capillary" early venous phase shows a prominent vascular
blush in lateral ventricle. Note "brain stain" depicting
parietooccipital, midbrain PCA supply.
AP VA DSA
Series of 3 AP views of a vertebrobasilar angiogram depict
the PCA segments and their branches. The
precommunicating (P1) segment is best seen in this
projection. The PCAs sweep laterally and then
posterosuperiorly around the midbrain.
Midarterial phase shows several of the cortical PCA
branches especially well. In this view, anterior and posterior
temporal arteries often overlap somewhat. In this
projection, the posterior thalamoperforating arteries are
seen as a faint vascular blush lying just above the terminal
basilar artery bifurcation.
Late arterial phase shows the vascular blush of the PCA
supply to the medial parietal and occipital lobes as well as
the temporal lobes. The unopacified vertical "filling defect" is
the dura of the falx cerebri that separates the 2 cerebral
hemispheres.
LATERAL, AP ICA DSA

Common normal variant is origin of the PCA from the
supraclinoid internal carotid artery (ICA), sometimes termed
a "fetal" origin of the PCA. In this instance, the ipsilateral P2
segment is hypoplastic or absent and the potential for
collateral flow through the circle of Willis is anatomically
limited. The meningohypophyseal trunk, a branch of the
cavernous ICA, is unusually prominent because it supplied a
small dural arteriovenous fistula (not shown) at the
transverse sinus/sigmoid sinus junction.
AP view shows the PCA is opacified from the internal
carotid injection. The vertebrobasilar angiogram in this
patient (not illustrated) showed "absent" filling of the right
PCA. The most common cause of this finding, as occurred
in this case, is "fetal" origin of the PCA from the ICA instead
of the vertebrobasilar system.
3T MRA
First of 3 views of an MRA obtained at 3T shows the PCA
and its major cortical branches. This slightly oblique lateral
view shows the basilar bifurcation and the P1 segment.
AP view shows both PCAs as they sweep laterally and then
posteriorly around the midbrain. Perforating arteries are not
well seen on MRAs, even at 3T.
Submentovertex view shows the PCA segments and distal
cortical PCA branches especially well. The configuration of
the PCA as it courses around the midbrain is highly variable.
The P1 (precommunicating) segments vary significantly in
size, length, and tortuosity.
AP CTA
Three coronal MIP reprojected views of a CTA depict the
segments of the PCA and some of their branches.
The ambient (P2) PCA segments sweep posterosuperiorly
around the midbrain just above the tentorium cerebelli. The
quadrigeminal (P3) segment is relatively short and begins at
the level of the dorsal midbrain near the quadrigeminal
plate. The basal vein of Rosenthal is opacified on this CTA
and should not be mistaken for the more laterally located
PCA.
This section, shown at the anterior end of the calcarine
fissure, depicts the terminal (P4) division of the right PCA
into its lateral (parietooccipital) and more medial (calcarine)
branches particularly well.
LATERAL CTA
First of 6 lateral views from a CTA depicts the PCA and its
branches. The medial posterior choroidal artery is the small
midline vessel lying just below the internal cerebral vein.
Note the splenial branch of the PCA anastomoses above
the corpus callosum with pericallosal branches from the
ACA. When either vessel is occluded, this may provide an
important source of potential collateral blood flow in addition
to pial (watershed) collaterals.
Vascular blush of the choroid plexus in the lateral ventricle is
seen here. It is supplied by the lateral posterior choroidal
artery.
The choroid plexus of the lateral ventricle, with its
accompanying arteries and veins, "dives" inferiorly through
the foramen of Monro.
More lateral section shows the parietal and occipital PCA
branches very well. The posterior temporal artery is also
seen here.
The lateral posterior choroidal artery originates from the P2
PCA segment and sweeps posterosuperiorly around the
pulvinar of the thalamus to supply it as well as the choroid
plexus.
This section through the posterolateral thalamus and atrium
of the lateral ventricle shows the lateral posterior choroidal
artery and its supply to the glomus of the choroid plexus.
AXIAL CTA
First of 3 axial MIP reconstructions from CTA depicts the
PCA segments especially well. Here, in the section through
the circle of Willis, 2 small posterior communicating arteries
are visualized. Both precommunicating (P1) PCA segments
are quite prominent.
Section through the ambient and quadrigeminal cisterns
shows their vascular contents, which include the P2 and P3
PCA segments as well as the more medially positioned
basal veins of Rosenthal.
In this section near the tentorial apex, the lateral posterior
choroidal arteries are seen as they supply the glomi of the
choroid plexus. The terminal division of the PCA into its
parietooccipital and calcarine branches occurs either in the
distal quadrigeminal cistern or near the anterior aspect of
the calcarine fissure.
Vertebrobasilar System
Main Text
T ERM INOLOGY
Abbreviations
• Vertebrobasilar (VB), vertebral artery (VA), basilar artery

(BA)
• Superior cerebellar arteries (SCAs), posterior inferior
cerebellar artery (PICA), anterior inferior cerebellar artery
(AICA)
• Anterior spinal artery (ASA), posterior spinal artery (PSA)
GROSS ANATOMY
Overview
• 4 VA segments
Extraosseous (V1) segment (arch → C6)
Foraminal (V2) segment (C6 → C1)
Extraspinal (V3) segment (C1 → foramen magnum)
Intradural (V4) segment (intracranial)
IMAGING ANATOMY
Overview
• Ectasia, tortuosity, off-midline course, variations in

configuration/branching patterns common
• VA
V1 : Arises from subclavian artery and courses
posterosuperiorly to enter C6 transverse foramen
V2
– Ascends through C6-C3 transverse foramina
– Turns superolaterally through inverted L-shaped
transverse foramen of axis (C2)
– Courses short distance superiorly through C1
transverse foramen
V3
– Exits top of atlas (C1) transverse foramen
– Lies on top of C1 ring, curving posteromedially
around atlantooccipital joint
– As it passes around back of atlantooccipital joint,
turns sharply anterosuperiorly to pierce dura at
foramen magnum
V4
– After VA enters skull through foramen magnum,
courses superomedially behind clivus
– Unites with contralateral VA at/near
pontomedullary junction to form BA
• BA
Courses superiorly in prepontine cistern (in front of
pons, behind clivus)
Bifurcates into its terminal branches, posterior cerebral
arteries (PCAs), in interpeduncular or suprasellar cistern
at/slightly above dorsum sellae
Branches
• VA
• VA
V1
– Segmental cervical muscular, spinal branches
V2
– Anterior meningeal artery, unnamed
muscular/spinal branches
V3
– Posterior meningeal artery
V4
– ASA, PSA
– Perforating branches to medulla
– PICA : Arises from distal VA, curves around/over
tonsil, gives off perforating medullary, choroid,
tonsillar, cerebellar branches
• BA
Pontine, midbrain perforating branches (numerous)
AICA
– Lies ventromedial to CNVII and CNVIII
– Often loops into internal auditory meatus
SCAs
– Arise from distal BA and course posterolaterally
around midbrain below CNIII, tentorium
– Lie above CNV and often contact it
PCAs (terminal BA branches)
Vascular Territory
• VA
ASA: Upper cervical spinal cord, inferior medulla
PSA: Dorsal spinal cord to conus medullaris
Penetrating branches: Olives, inferior cerebellar
peduncle, part of medulla
PICA: Lateral medulla, choroid plexus of 4th ventricle,
tonsil, inferior vermis/cerebellum
• BA
Pontine perforating branches: Central medulla, pons,
midbrain
AICA: Internal auditory canal, CNVII and CNVIII,
anterolateral cerebellum
SCA: Superior vermis, superior cerebellar peduncle,
dentate nucleus, brachium pontis, superomedial surface
of cerebellum, upper vermis
• Normal variants
VA: Right/left variation in size, dominance common;
aortic arch origin: 5%
BA: Variation in course, branching patterns common
(e.g., AICA/PICA may share common trunk)
• Anomalies
VA/BA may be fenestrated, duplicated (may have
increased prevalence of aneurysms)
Embryonic carotid-basilar anastomoses (e.g., persistent
trigeminal artery)
EMBRYOLOGY
Embryologic Events
• Plexiform longitudinal anastomoses between cervical

intersegmental arteries → VA precursors
• Paired plexiform dorsal longitudinal neural arteries (LNAs)
develop, form precursors of BA
• Transient anastomoses between dorsal LNAs, developing
ICAs appear (primitive trigeminal/hypoglossal arteries, etc.)
• Definitive VAs arise from 7th cervical intersegmental
arteries, anastomose with LNAs
• LNAs fuse as temporary connections with ICAs regress →
definitive BA, VB circulation formed
Image Gallery
Print Images
GRAPHIC, 3D-VRT CTA
AP graphic shows 2 of the 3 extracranial segments of the

vertebral arteries (VAs) and their relationship to the cervical
spine. The extraosseous (V1) VA segments extend from the
superior aspect of the subclavian arteries to the C6
transverse foramina. The V2 (foraminal) segment extends
from C6 to the VA exit from the C1 transverse foramina.
For comparison with the previous graphic, a 3D-VRT CTA

shows the extracranial VAs. They originate from the
superior aspect of the subclavian arteries. The VAs typically
enter the transverse foramina of C6 and ascend almost
vertically to C2 where they make a 90° turn laterally in the
L-shaped C2 transverse foramen before ascending
vertically again to C1.
GRAPHICS
AP graphic depicts the distal cervical and intracranial

vertebrobasilar (VB) system. V3 is the short extraspinal VA
segment that extends from the top of C1 to the foramen
magnum. V4 is the intradural (intracranial) segment. A right
posterior inferior cerebellar artery (PICA) originates from
the VA. A combined anterior inferior cerebellar artery
(AICA)-PICA trunk is a common normal variant and is
shown on the left.
Lateral graphic depicts the VB system. Note that the
relationship of PICA loops to the medulla and cerebellar
tonsil. Watershed between superior cerebellar artery (SCA)
and PICA is often near the great horizontal fissure of the
cerebellum.
GRAPHICS
Persistent carotid-basilar anastomoses are depicted. This
lateral graphic depicts a persistent trigeminal artery (PTA).
Note the typical Neptune-trident appearance formed by the
internal carotid artery (ICA) and PTA. A hypoplastic VA
ends in PICA and AICA. The BA between the AICA and
PTA is absent. The PCoA is also absent. This is a Saltzman
type I PTA.
Persistent (primitive) hypoglossal artery (PHA) is shown,
originating from the ICA at C1-2 level and passing
posterosuperiorly through an enlarged hypoglossal canal.
The PHA does not traverse the foramen magnum and
supplies the distal BA. The ipsilateral VA is hypoplastic.
Proatlantal intersegmental artery arises from the ICA at C2-
3 and courses posterosuperiorly between C1 and the
occiput to join the VA.
3D-VRT CTA
A series of 3 close-up views from a 3D-VRT CTA elegantly
illustrates the relationship of the VA to the C1 and C2
vertebral bodies. Lateral projection shows that the VA
makes a 90°, L-shaped turn laterally through C2 then
ascends between C2 and C1. After it exits the C1
transverse foramen, it courses posteriorly above and along
the C1 ring. A posterior bony ring (ponticulus posticus) is
present in this case, a normal variant.
3D-VRT CTA with close-up view shows the distal VA as it
follows its complex course through the C2 and C1
transverse foramina. The VAs are shown from the AP
(frontal) projection.
The VA as it courses posterolaterally around the C1 lateral
mass and above the C1 ring is clearly seen on this view.
The VA then turns anteromedially to enter the foramen
magnum. Note the bony ring over the right VA, a normal
variant.
Patient-specific 3D CT angiography was segmented by Drs.
Adriene Eastaway, Michael Bayona, and Edward Quigley in
Materialise Mimics, and edited in Materialise 3-matic. This
was rendered with subsurface and dynamic lighting using
Sketchfab. Presented at ASNR Vancouver, 2018.
Vertebrobasilar system with codominant vertebral arteries
and basilar tip aneurysm is demonstrated.
DSA
Close-up AP view of a right vertebral DSA shows the
extracranial VA as it courses cephalad in the transverse
foramina of C6 to C3. Segmental spinal rami and muscular
branches arise from the V2 (foraminal) VA segment. Here,
a prominent spinal ramus is large enough to reach the
anterior median sulcus of the spinal cord where it divides
into ascending and descending branches. These
anastomose with the anterior spinal artery, which arises
from the intradural VA.
Lateral DSA of a vertebral angiogram shows the upper V2
(foraminal), V3 (extraspinal), and V4 (intradural) VA
segments. Note prominent spinal arteries and anastomosis
with muscular branches of the external carotid artery (ECA).
AP view shows a VA coursing through the C2-C1 transverse
foramina and above the C1 ring together with its anterior
turn into the foramen magnum, forming a "1/2 square."
LATERAL DSA
Lateral view of a left vertebral DSA, early arterial phase,
shows the intracranial VB system. PICA and its proximal
loops are especially well seen. PICA has 4 segments and 2
distinct loops. The caudal or inferior loop is along the
inferior medulla and may be as low as C2. The 2nd (cranial)
loop occurs as PICA courses above or across the
cerebellar tonsil.
Midarterial phase shows distal branches of the VA and BA.
Note important vascular anastomosis between muscular
branches of the VA and the occipital artery (an external
carotid branch). The PCoA and its thalamoperforating
branches are opacified.
Late arterial phase shows normal vascular "blush" in the
territory supplied by the VB system. This includes the
brainstem, vermis, cerebellum, occipital lobe, posterior
thalami, and some choroid plexus.
AP DSA
AP view of a right vertebral DSA, early arterial phase,
shows origins of the major vertebral (VA) and basilar (BA)
branches. Contrast has refluxed into the left VA, which is
partially filled with unopacified blood. In this case, both the
PICAs and AICAs arise separately from the vertebral and
basilar arteries, respectively.
Midarterial phase shows the hemispheric branches of both
PICAs, AICAs, and SCAs. The right AICA is seen as it
loops into the internal auditory canal (IAC).
Later phase shows a dense vascular "blush" of the entire
cerebellum and occipital lobes and nicely demonstrates the
VB vascular territory. The tentorium and falx are seen as
thin, unopacified areas between the cerebellar hemispheres
and occipital lobes.
3T MRA
Slightly oblique lateral view of an MRA shows the
intracranial VB circulation. Here, the PICAs and AICAs are
especially well seen.
AP view shows the distal basilar bifurcation and more
proximal branches. Two prominent SCAs are well seen
here. On the left, a prominent VA branch is an AICA-PICA
trunk. Common origin of these 2 branches from the VA is a
frequent normal variant.
Submentovertex view shows the BA bifurcation especially
well. The posterior cerebral and superior cerebellar
branches are superimposed and loop laterally around the
midbrain.
SECT ION 9
VEINS AND VENOUS SINUSES
Outline

Intracranial Venous System Overview
Main Text
T ERM INOLOGY
Abbreviations
• Superior sagittal sinus (SSS)

• Inferior sagittal sinus (ISS)
• Internal cerebral vein (ICV)
• Straight sinus (SS)
• Great cerebral vein [vein of Galen (VofG)]
• Transverse sinus (TS)
• Superior/inferior petrosal sinuses (SPS/IPS)
• Internal jugular vein (IJV)
• Basal vein of Rosenthal (BVR)
• Superficial, deep middle cerebral veins (SMCV; DMCV)
Definitions
• Dural sinuses are large, endothelial-lined trabeculated

venous channels encased within folds/reflections of dura
that define, form their walls
• Cerebral veins are thin-walled, valveless structures that
cross SAS, pierce arachnoid/inner dura to enter dural
venous sinus
GROSS ANATOMY
Overview
• Dural venous sinuses (divided into 2 groups)

Anteroinferior group (CS, SPS/IPS, clival,
sphenoparietal)
Posterosuperior group (SSS, ISS, SS, TS, sigmoid,
occipital)
• Cerebral veins (divided into 3 groups)
Superficial ("external") veins (3 subgroups)
– Superior: 8-12 smaller cortical veins over
hemispheres, vein of Trolard
– Middle: SMCV, vein of Labbé
– Inferior: DMCV, BVR
Deep ("internal") veins
– Subependymal veins
– ICVs (formed by thalamostriate, septal veins)
– Great cerebral vein (VofG)
Brainstem/posterior fossa veins (3 subgroups)
– Superior (galenic) group
– Anterior (petrosal) group
– Posterior (tentorial) group
Vascular Territories
• Venous vascular territories

More variable, less well known than arterial territories
General concepts
– Venous drainage generally radial, centrifugal
(exception = deep cerebral structures)
– Much of middle/superior brain surfaces (cortex,
subcortical white matter) drained by cortical veins to
SSS
– Posterior/inferior temporal lobe, adjacent parietal
lobe drained by vein of Labbé to TS
– Insular cortex, parenchyma around sylvian (middle
cerebral) fissure drained by sphenoparietal sinus to
CS
– Deep cerebral structures (central/deep white matter,
basal ganglia) drained by medullary/subependymal
veins to ICVs, VofG, SS; medial temporal lobe via
DMCV/BVR to VofG
• Dural venous sinuses

Communicate with extracranial veins directly (via diploic
veins in calvarium, emissary veins through basilar
foramina)
Receive venous blood from superficial (cortical) veins,
deep (subependymal) veins
• Cerebral veins
Superficial (cortical) veins lie in SAS, mainly follow sulci
Subependymal veins outline ventricles
IMAGING ANATOMY
Overview
• Dural venous sinuses

Visualization at DSA varies widely
– Almost always: SSS, SS, TS, sigmoid sinus, IJVs
– Sometimes: ISS, SPS/IPS
– Rare/inconstant: CS, sphenoparietal sinus, occipital
sinus, clival (basal) venous plexus
• Cerebral veins
Superficial cortical veins almost always seen (number,
configuration vary)
Deep veins almost always seen on late venous phase of
DSA, only largest (e.g., thalamostriate veins) seen on
MR/MRV
ICVs, VofG almost always seen on DSA, CTV, MRV

• Obtain source images for MR venogram perpendicular to

main axis of dural sinus (e.g., coronal for SSS)
• MRV, CTV excellent for general overview of dural sinuses,
cerebral veins but DSA best for detailed delineation
Imaging Pitfalls
• TSs often asymmetric, hypoplastic/atretic segment common

(do not misdiagnose as occlusion)
• Saturation bands on MR disguise flow
• Jugular bulb flow often very asymmetric, turbulent
(pseudolesion)
• Unopacified venous blood streaming into dural sinus on
DSA should not be mistaken for filling defect (thrombus)
• "Giant" arachnoid granulations appear as round/ovoid
cerebrospinal fluid-equivalent filling defects in dural sinuses
(especially TS), are a normal variant, should not be mistaken
for thrombus
• Acute dural sinus, cortical vein thrombi isointense with
brain on T1WI so T2* (GRE) or T1 C+ imaging very helpful
• Subacute clot is hyperintense on T1WI (do not mistake for
enhancement)
Image Gallery
Print Images
GRAPHICS
A series of 3 graphics provides an overview of the

intracranial veins and their drainage territories. The first of
these, a 3D rendering of falx cerebri with major dural
sinuses and deep veins, shows the interconnections
between these 2 venous systems.
Intracranial view depicts the major dural venous sinuses as
seen from the top down. The cerebral hemispheres,
midbrain, and pons as well as the left 1/2 of the tentorium
cerebelli have been removed. Note the numerous
interconnections between both halves of the cavernous
sinus (CS), the clival venous plexus, and the petrosal
sinuses.
A series of 4 axial sections depicts typical venous drainage
patterns of the cerebral hemispheres. In general, the deep
white matter and basal ganglia are drained by the internal
cerebral vein (ICV) and its tributaries (such as medullary
veins).
AXIAL CECT
Series of 6 selected axial CECT images through the brain
from inferior to superior are shown. Contrast in the lateral
dural wall of the CS is seen on this section.
Section through the midbrain shows dura of the tentorium
cerebelli with adjacent basal veins of Rosenthal (BVR) and
lateral mesencephalic veins.
Section through the foramen of Monro shows septal veins
as they curve around the pillars of the fornix behind the
frontal horns of both lateral ventricles. The larger, midline
enhancing area represents the choroid plexus as it is
passing inferiorly from the lateral ventricles and forming the
posterior border of the foramen of Monro. The anterior
border is formed by the pillars of the fornix.
Scan at the level of the upper foramen of Monro is shown.
The vein of Galen (VofG), a U-shaped structure, is seen
here with its anterior and posterior segments seen as 2
contrast-filled "dots" that curve above the pineal gland and
under the corpus callosum splenium.
Section through the ICVs, paired paramedian structures,
shows their extent from the thalamostriate tributaries
anteriorly to the VofG posteriorly.
Scan through the upper ventricles and tentorial apex is
depicted. Anterior caudate veins are subependymal
tributaries of the thalamostriate veins. The septal and
thalamostriate veins join to form the ICVs.
3T AXIAL T1 C+ MR
Series of 9 axial T1 C+ MR scans from inferior to superior
are shown. Note inhomogeneous flow in the jugular bulb.
This is normal and should not be mistaken for a mass or
thrombus (jugular "pseudolesion").
Section through the lateral recesses of the 4th ventricle
shows the inferior petrosal sinuses, tributaries of the jugular
bulb. The pterygoid venous plexus and the venous plexus in
the foramen ovale are connected through the skull base to
the CS. These intra- to extracranial connections may
provide an important source of collateral venous drainage if
the CS becomes occluded.
Section through the CS shows connections with the clival
plexus and the orbit (inferior ophthalmic vein). Petrosal veins
in the cerebellopontine angle cistern are prominent but
normal in this case.
The CS is especially well seen on this scan. Again note
prominent petrosal veins in the upper cerebellopontine angle
cisterns. The faint enhancement seen along the anterior
belly of the pons is the anterior pontomesencephalic venous
plexus and is normal, and should not be mistaken for
meningitis or leptomeningeal carcinomatosis.
Section through the upper CS shows the intercavernous
plexus surrounding the opening of the diaphragma sellae,
which contains the infundibular stalk. The superior
ophthalmic vein drains posteriorly into the CS.
Section through upper vermis shows the left BVR curving
around midbrain, coursing posteriorly toward its confluence
with the ICVs at the VofG. The superficial middle cerebral
vein drains into the sphenoparietal sinus (shown on the
lower section, above). The deep middle cerebral vein drains
into the BVR and VofG.
The paired ICVs as they terminate in the VofG are shown.
Note the BVRs terminating with the ICVs to form the great
cerebral VofG.
Section through the foramen of Monro shows the septal,
anterior caudate vein and thalamostriate tributaries of the
ICVs.
Most cephalad section shows prominent frontal superficial
cortical veins, tributaries of the superior sagittal sinus.
3T LATERAL, OBLIQUE, AND AP MRV

Lateral view from an MRV demonstrates cerebral venous
drainage. Dural venous sinuses and superficial cortical veins
are well depicted on this lateral view.
Oblique view of the MRV shows dural sinuses draining
posteroinferiorly to torcular Herophili, which splits into 2
nearly symmetric transverse sinuses (TS).
AP view shows superimposed superior sagittal and straight
sinuses, which demonstrates slight but normal asymmetry
of the TSs. Larger (left) and smaller (right) veins of Labbé
are seen here as they drain into the TS. The vein of Labbé
can be quite large and drain a significant territory over the
inferolateral cerebral hemisphere. If the TS becomes
occluded, the vein of Labbé may also thrombose and cause
a large venous infarct.
Selected References
1. Scott, JN, et al. Imaging and anatomy of the normal
intracranial venous system. Neuroimaging Clin N Am. 2003;
13(1):1–12.
Dural Sinuses
Main Text
T ERM INOLOGY
Abbreviations
• Internal cerebral vein (ICV)

• Superior/inferior petrosal sinuses (SPS/IPS)
GROSS ANATOMY
• Endothelial lined, contained within outer (periosteal), inner

(meningeal) dural layers
• Often fenestrated, septated, multichanneled
• Contain arachnoid granulations, villi
Extension of subarachnoid space (SAS) + arachnoid
through dural wall into lumen of venous sinus
Returns cerebrospinal fluid (CSF) to venous circulation
IMAGING ANATOMY
Overview
• Superior sagittal sinus (SSS)

Appears as curvilinear structure that hugs inner calvarial
vault
– Originates from ascending frontal veins anteriorly
– Runs posteriorly in midline at junction of falx cerebri
with calvarium
Collects superficial cortical veins, increases in diameter as
it courses posteriorly
Terminates at venous sinus confluence (often runs off
midline posteriorly)
Important hemispheric tributary: Vein of Trolard
• Inferior sagittal sinus (ISS)
Smaller, inconstant channel in inferior (free) margin of
falx cerebri
Lies above corpus callosum, from which it receives
tributaries
Terminates at falcotentorial apex, joining with vein of
Galen (VofG) to form straight sinus (SS)
• Straight sinus (SS)
Runs from falcotentorial apex posteroinferiorly to sinus
confluence
Receives tributaries from falx, tentorium, cerebral
hemispheres
• Torcular Herophili (venous sinus confluence)
Formed from union of SSS, SS, transverse sinuses (TSs)
Often asymmetric, interconnections between TS highly
variable
• Transverse sinuses (TSs) (lateral)
Contained between attachment of tentorial leaves to
calvarium
Extends laterally from torcular to posterior border of
petrous temporal bone
Often asymmetric (right side usually larger than left)
Hypoplastic/atretic segment common
Tributaries from tentorium, cerebellum, inferior
temporal/occipital lobes
Important tributary: Vein of Labbé
• Sigmoid sinuses
Anteroinferior continuation of TSs
Gentle, S-shaped inferior curve
Terminate by becoming internal jugular veins
• Cavernous sinuses (CSs)
Irregularly shaped, trabeculated venous compartment
along sides of sella turcica
Contained within prominent, lateral, thin (often
inapparent) medial dural wall
Extends from superior orbital fissure anteriorly to clivus
and petrous apex posteriorly
Contains cavernous ICA, CNVI (inside CS itself) and III,
IV, V1 and V2 (within lateral dural wall)
Tributaries include superior/inferior ophthalmic veins,
sphenoparietal sinus
Communicate inferiorly with pterygoid venous plexus,
medially with contralateral CS, posteriorly with SPS/IPS,
clival venous plexus
Inconstantly visualized at digital subtraction
angiography
• Miscellaneous dural venous sinuses
SPS (runs along petrous ridge from CS to sigmoid sinus)
IPS (runs along petrooccipital fissure from clival venous
plexus to jugular bulb)
Sphenoparietal sinus (runs along lesser sphenoid wing
from sylvian fissure to CS or IPS)
Occipital sinus (from foramen magnum to torcular)
Clival venous plexus (network of veins along clivus from
dorsum sellae to foramen magnum)
• Common variants
Absent anterior SSS (may begin posteriorly near coronal
suture)
"Off-midline" SSS terminating directly in TS
Absence or hypoplasia of part/all of TS
Jugular bulbs can vary greatly in size, configuration (can
be "high riding," have jugular diverticulum, dehiscent
jugular bulb)
"Giant" arachnoid granulations (round/ovoid, CSF-
equivalent filling defects in dural sinuses)
• Anomalies
Persistent embryonic falcine sinus (usually with VofG
malformation)
Lambdoid-torcular inversion with high sinus confluence
(with Dandy-Walker spectrum)

• Examine source images (not just reprojected views) of

MRV/CTV
• DSA rarely required to diagnose dural sinus occlusion
• Acute dural sinus thrombus is isointense with brain on
T1WI, profoundly hypointense on T2WI (may mimic "flow
void") so T2* or T1 C+ imaging very helpful
• Subacute clot hyperintense on T1WI so precontrast scan
needed to compare to T1 C+ images
Imaging Pitfalls
• TSs often asymmetric, hypoplastic/atretic segment common

(do not misdiagnose as occlusion)
• Jugular bulbs often very asymmetric, turbulent flow
(pseudoocclusion)
Image Gallery
Print Images
GRAPHICS
A series of color graphics depicts the major intracranial

dural venous sinuses and their tributaries. This sagittal
midline graphic shows an overview of the relationship of the
midline venous sinuses to adjacent structures. The vein of
Galen curves under the corpus callosum splenium, above
the pineal gland, and joins the straight sinus at the
falcotentorial junction.
The falx cerebri extends posteriorly from its origin at the
crista galli to the falcotentorial junction. The superior sagittal
sinus is enclosed in its superior borders and may begin as
far anteriorly as the crista galli or as far posteriorly as the
coronal suture.
This graphic, with the brain removed and the sinuses at the
skull base seen from above, shows the numerous
interconnections between the cavernous sinus, clival venous
plexus, and sphenoparietal and petrosal sinuses.
The cavernous sinus and its contents are shown in coronal
section. The cavernous sinus is fenestrated, septated, and
multichanneled. The cavernous internal carotid artery and
the abducens (CNVI) nerve are the only structures that
actually lie within the cavernous sinus itself. Most of the
cranial nerves are contained in the lateral dural wall of the
cavernous sinus. The medial dural wall is generally not
apparent.
Lateral view shows the dural-covered cavernous sinus and
its nerves (the internal carotid artery is not depicted).
Meckel cave is a dura and arachnoid-lined extension of the
prepontine cerebrospinal fluid (CSF) cistern into the
cavernous sinus. It contains the fascicles of the trigeminal
nerve and ganglion. The 3rd (mandibular) division of CNV
exits the skull through the foramen ovale without passing
through the cavernous sinus itself. All cranial nerves, except
for CNVII, are in the lateral wall.
LATERAL ICA DSA

Series of 3 lateral views of an internal carotid DSA is
shown. Early venous phase shows the superficial cortical
and anastomotic veins are most prominent, and the venous
sinuses are only faintly opacified.
Midvenous phase shows prominent opacification of the dural
venous sinuses. The cavernous sinus is well seen, along
with its interconnections with the pterygoid venous plexus.
Late venous phase shows contrast has been washed out of
most of the cortical veins. The subependymal veins are
quite prominent at this stage and are well seen with the
disappearance of contrast from overlying cortical veins. A
very prominent filling defect in the descending segment of
the superior sagittal sinus, caused by a large arachnoid
granulation, is now well seen. The transverse and sigmoid
sinuses are a more common location for arachnoid
granulations.
AP ICA DSA
Series of 2 AP venous phase angiograms is shown. Early
venous phase shows prominent filling of numerous
superficial cortical veins. The anterior aspect of the superior
sagittal sinus is faintly opacified. If the AP view is perfectly
straight, as it is in this case, the superior and inferior
sagittal sinuses, internal cerebral vein, and vein of Galen
overlap in the midline.
Midvenous phase shows major dural venous sinuses. The
right transverse sinus is dominant and fills prominently, even
though contrast was injected into the left internal carotid
artery.
Late phase shows the subependymal veins especially well.
A less well-visualized segment of the left transverse sinus is
seen, a normal variant that should not be mistaken for
venous occlusion. Filling defect in the superior sagittal sinus
is caused by a very large arachnoid granulation. The internal
cerebral vein arcs posteriorly to the vein of Galen from its
origin at the anterior thalamostriate vein.
OBLIQUE ICA DSA

Series of 3 oblique AP views of a right internal carotid DSA
is shown. The early venous phase shows prominent
superficial cortical veins. The superior sagittal and
transverse sinuses are faintly opacified. This view is ideal
for visualizing sinus occlusion.
In this midvenous phase, both superficial and deep veins are
visualized well, as are the major dural venous sinuses. In
this case, the superior sagittal sinus arcs posteriorly all the
way from the crista galli anteriorly to the sinus confluence
posteriorly.
Late venous phase shows a prominent filling defect in the
superior sagittal sinus caused by a giant arachnoid
granulation, a normal variant.
3T AXIAL T1 C+ MR
is shown. Section through the lower medulla and jugular
foramen shows the sigmoid sinuses and right jugular bulb.
Asymmetry of the jugular bulbs, seen here, is very common,
as is inhomogeneous flow and enhancement pattern.
Scan through the midpons includes the junction of the
transverse with the sigmoid sinuses.
Scan through the cavernous sinus shows its
interconnections with the sphenoparietal sinuses anteriorly
and the clival venous plexus posteriorly. The left superior
petrosal sinus is shown draining into the transverse sinus.
The superficial middle cerebral veins are shown on the right
and the sphenoparietal sinus on the left. Note the prominent
tentorial veins draining into both transverse sinuses.
Section through the upper lateral cerebral (sylvian) fissure
shows the superficial middle cerebral vein on the right. Both
basal veins of Rosenthal are well seen. The junction
between the straight sinus and torcular Herophili is included.
Scan through the tentorial apex shows the internal cerebral
veins and basal veins of Rosenthal forming the vein of
Galen.
Scan through the foramen of Monro shows the
thalamostriate and anterior caudate veins (cut across). The
left septal vein is faintly seen in front of the frontal horn of
the lateral ventricle. Both the small anterior and larger
posterior aspects of the superior sagittal sinus are seen.
Section through the upper bodies of the lateral ventricles
shows prominent unnamed frontal cortical veins draining into
the anterior aspect of the superior sagittal sinus. Note "flow
void" in the posterior aspect of the superior sagittal sinus, a
normal finding caused by fast venous flow.
The anterior and posterior aspects of the superior sagittal
sinus are depicted on this upper section. A small portion of
the inferior sagittal sinus can be identified in the
interhemispheric fissure. The superior sagittal sinus
increases in size as it passes posteriorly and collects
cortical hemispheric veins.
3T AP, LATERAL MRV; 3D CTV

AP view of an MRV depicts the major dural venous sinuses
well. If large, anastomotic veins, such as the vein of Labbé,
can be visualized on MRV. Narrowing/stenosis of the
transverse/sigmoid sinus junction is often present in patients
with idiopathic intracranial hypertension.
Lateral view of the MRV shows the intracranial dural
sinuses, anastomotic vein of Labbé, and some of the major
extracranial veins.
Patient-specific 3D CT venogram was segmented by Drs.
Adriene Eastaway and Edward Quigley and edited in
Materialise Mimics, Materialise 3-matic. This was
cinematically rendered using Maya and AfterEffects. Near-
posterior view shows the superior sagittal sinus, torcular
Herophili (sinus confluence), dominant right transverse
sinus, and hypoplastic left transverse sinus.
Superficial Cerebral Veins
Main Text
T ERM INOLOGY
Abbreviations
• Superficial middle cerebral vein (SMCV)

• Deep middle cerebral vein (DMCV)
• Vein of Trolard (VofT)
• Vein of Labbé (VofL)
• Basal vein of Rosenthal (BVR)
• Superior, inferior sagittal sinus (SSS; ISS)
• Sphenoparietal sinus (SPS)
• Great cerebral vein [vein of Galen (VofG)]
Synonyms
• Cortical veins: Superficial or external veins
GROSS ANATOMY
Overview
• Highly variable in number and configuration

• Located within subarachnoid space (SAS), cisterns
• Organized anatomically into 3 groups (superior, middle,
inferior)
• Superior group
8-12 superficial cortical veins
Follow sulci, ascend to convexity
Cross SAS
Pierce arachnoid and inner dura, join SSS at right angles
• Middle group
SMCV
– Inconstant, variable size/dominance
– Begins over surface of lateral (sylvian) fissure
– Collects numerous superficial veins from frontal,
temporal, parietal operculae
– Curves anteromedially around temporal lobe
– Terminates in CS or SPS
• Inferior group
Orbital surface of frontal lobe drains superiorly to SSS
Temporal lobe, anterior cerebral veins anastomose with
deep middle cerebral and basal veins
Basal vein (of Rosenthal)
– Begins near anterior perforated substance
– Receives anterior cerebral, DMCV tributaries (from
insula, basal ganglia, parahippocampal gyrus)
– Curves posteriorly around cerebral peduncles
– Drains into great cerebral vein (VofG)
• 3 major named large anastomotic cortical veins
VofT : Major superior anastomotic vein
VofL : Major inferior anastomotic vein
SMCV : Major middle anastomotic vein
• Anastomotic veins
Have reciprocal relationship (if 1 is large, others typically
smaller or absent)
Abundant anastomoses with each other, as well as deep
(internal) cerebral veins, orbit, extracranial venous plexi
Vascular Territories
• Superior group
Cortical veins + SSS, ISS
Venous drainage territory
– Superolateral hemispheric surfaces
– Most of medial hemispheric surfaces between ISS
and SSS
– Most of frontal lobes except for perisylvian area
• Middle group
SMCV + CS
Venous drainage territory
– Perisylvian area
– Anterior temporal lobes
• Inferior group
BVR
– Drains inferior insula, basal ganglia, medial temporal
lobes
VofL (+ TS)
– Drains posterior temporal, lower parietal lobes
IMAGING ANATOMY
Overview
• Highly variable; asymmetry between hemispheres common

• Superior group
Lateral DSA
– Arranged in spoke-like pattern
– Converge with SSS at right angles
– Prominent VofT from sylvian fissure to SSS usually
seen coursing over parietal lobe
AP DSA: Stepladder appearance from front to back
• Middle group
Lateral DSA: SMCV has single or multiple trunks that
follow sylvian fissure, curve over temporal tip
AP DSA: SMCV drains into CS, SPS, or through foramen
ovale into pterygoid venous plexus
• Inferior group
Lateral DSA: BVR curves somewhat inferiorly as it passes
around midbrain
AP DSA: BVR curves laterally around midbrain to VofG

• MRV
Obtain source images perpendicular to veins of interest
– e.g., for suspected SSS thrombosis, use coronal
source images
Imaging Pitfalls
• VofT variable in size, position; may appear quite posterior

on axial MR/CT scans
EMBRYOLOGY
Embryologic Events
• 8 weeks
Primitive, thin-walled plexus of undifferentiated vascular
channels covers brain surface
Persistence of primitive leptomeningeal vascular plexus,
paucity of normal cortical veins → Sturge-Weber
syndrome
– Somatic mutation inGNAQ gene
• 10-12 weeks
Progressive anastomosis, retrogressive differentiation
cause plexi to coalesce into definitive cortical venous
channels
Failure to coalesce → persistence of primitive, plexiform
veins (common with malformations of cortical
development)
Image Gallery
Print Images
GRAPHICS
Coronal graphic through the superior sagittal sinus (SSS)
depicts venous drainage of the superior hemispheres,
illustrating how small penetrating cortical veins collect
venular tributaries and then exit the cortex and enter the
subarachnoid space (SAS) (cerebral sulcus). Cortical veins
within the sulci collect numerous tiny draining veins and then
course through the SAS toward the arachnoid. They pass
through the arachnoid and inner (meningeal) dural layer to
empty into the SSS. Within the SAS, the veins are covered
with a thin layer of cells that is continuous with the pia and
inner surface of the arachnoid.
Inferior view shows major veins of the inferior brain and
sylvian fissure. The superficial middle cerebral vein (SMCV)
(cut off) drains into the cavernous sinus (not shown). The
anterior cerebral and deep middle cerebral vein (DMCV)
join with other veins to form the basal vein of Rosenthal
(BVR).
Lateral graphic depicts the superficial cortical veins and
their relationship to the dural venous sinuses. The 3 named
anastomotic veins [SMCV, vein of Trolard (VofT), vein of
Labbé (VofL)] are depicted here as all relatively similar in
size. It is common to have 1 or 2 dominant anastomotic
veins with hypoplasia of the other(s) present.
Cortical venous tributaries of the SSS are seen from above.
Two configurations of the VofT are depicted. On the left,
the VofT courses directly superiorly from the sylvian fissure.
On the right, the VofT sweeps more posteriorly.
LATERAL INTERNAL CAROTID ARTERY DSA

A series of 3 venous phase lateral internal carotid artery
(ICA) DSAs from different cases is shown to illustrate the
superficial cerebral veins. Several superior cortical veins are
present without a dominant, identifiable VofT. Here, the
SMCV is large, and a smaller VofL is present. The major
drainage of the SMCV is into the pterygoid plexus with a
smaller pathway through a hypoplastic superior petrosal
sinus into the sigmoid sinus.
In this case, a prominent SMCV is present. Note the filling
of the superior ophthalmic vein, which communicates with
the cavernous sinus (not well seen) and facial veins.
In this case, all 3 anastomotic veins are visualized. All are
approximately equal in size with no dominant anastomotic
pattern. This is a relatively unusual finding.
AP DSA
A series of 3 AP venous phase angiograms is shown. Here,
a slightly oblique view shows several unnamed cortical
veins. On AP views, the cortical veins form a stepladder
appearance as they drain from the hemispheric surface up
to the SSS. The SSS increases in size as it passes from
front to back.
Another case shows a very prominent VofT (superior
anastomotic vein). Other unnamed smaller cortical veins
have the classic stepladder appearance on this projection.
This case has a prominent VofT (superior anastomotic vein)
that originates at the sylvian fissure and passes superiorly
over the hemisphere. A smaller SMCV is seen draining into
the sphenoparietal sinus. No VofL (inferior anastomotic vein)
is seen. A small inferior sagittal sinus is present, seen
overlying the SSS.
3T MRV, CTV
Lateral view MRV demonstrates a prominent VofT and
SMCV. The VofL (inferior anastomotic vein) is relatively
small. Prominent frontal veins contribute to the origin of the
SSS.
AP view of an MRV shows a prominent right VofT. A small
VofL is seen. In this case, the transverse sinuses are equal
in size.
Patient-specific 3D CTV was segmented by Drs. Adriene
Eastaway, Michael Bayona, and Edward Quigley, edited in
Materialise Mimics, Materialise 3-matic, and cinematically
rendered using Maya and AfterEffects with subsurface and
dynamic lighting, transparency of the calvarium, and opacity
of skull base for orientation. This 3D display nicely shows a
dominant vein of Trolard with multiple smaller, unnamed
superficial cortical veins draining into the superior sagittal
sinus. Superficial, deep middle cerebral veins are smaller
with multiple small tributaries draining the temporal lobe.
Deep Cerebral Veins
Main Text
T ERM INOLOGY
Abbreviations
• Septal, thalamostriate, internal cerebral veins (SV, TSV, ICV)

• Vein of Galen (VofG); basal vein of Rosenthal (BVR)
• Inferior sagittal sinus (ISS); straight sinus (SS)
Definitions
• Cavum veli interpositi: Space within double-layered tela

choroidea of 3rd ventricle, communicates posteriorly with
quadrigeminal cistern
GROSS ANATOMY
Overview
• Medullary veins
Small, linear veins originate 1-2 cm below cortex
Course toward ventricles, terminate in subependymal
veins
• Subependymal veins
SV
– Course posteriorly along septum pellucidum
– Join with TSVs to form ICVs at interventricular
foramen
TSVs
– Receive caudate/terminal veins that course anteriorly
between caudate nucleus, thalamus
– Curve over caudate nuclei
– Terminate at interventricular foramen (of Monro) by
uniting with SVs to form ICVs
• Deep paramedian veins
ICVs
– Paired, paramedian
– Course posteriorly in cavum veli interpositi
– Terminate in rostral quadrigeminal cistern by uniting
with each other; BVRs to form VofG
VofG (great cerebral vein)
– Short, U-shaped midline vein formed from union of
ICVs, BVRs
– Curves posteriorly and superiorly under corpus
callosum splenium in quadrigeminal cistern
– Unites with ISS at falcotentorial apex to form SS
• Deep veins course under ventricular ependyma, define

ventricular margins
• ICVs above 3rd ventricle, pineal gland; under fornices,
corpus callosum splenium
Vascular Territory
• ICVs, VofG, and tributaries drain ovoid area surrounding

lateral/3rd ventricles
• Caudate nuclei, putamen/globus pallidus, thalamus, internal
capsule, deep cerebral (medullary) white matter, medial
temporal lobes
IMAGING ANATOMY
Overview
• Medullary veins
On DSA, appear as tiny, relatively uniform, contrast-
filled, linear structures that terminate at right angles to
ventricular subependymal veins
• Subependymal veins
DSA, lateral view
– "Dots" of contrast at subependymal/medullary vein
junction define roof of lateral ventricle
DSA, AP view
– TSV defines size, configuration of lateral ventricle;
characteristic double curve appearance
– BVR, tributary of VofG, begins at medial temporal
lobe, curves around midbrain, appears as frog leg
T1 C+ MR usually shows TSV, caudate, and SVs; smaller
subependymal veins usually inapparent
• Deep paramedian veins
DSA, lateral view
– ICV follows gently undulating posterior course from
foramen of Monro to VofG
– VofG forms prominent arc, curving back/up around
corpus callosum splenium
DSA, AP view
– ICVs 1-2 mm off midline, seen as ovoid/elliptical
collection of contrast
T1 C+ MR, axial view: ICVs seen as contrast-filled, linear,
paramedian structures just above 3rd ventricle
CTV/MRV: ICVs, VofG well seen
• Variations common; true anomalies rare

• Variations common; true anomalies rare
• VofG malformation
Primitive median prosencephalic vein (MPV) persists as
outlet for diencephalic, choroidal venous drainage
Persisting falcine sinus ± absent/hypoplastic SS

• MRV/CTV delineate dural sinuses, large deep veins (e.g.,

ICV, BVR)
• DSA best for detailed delineation of deep veins/tributaries
EMBRYOLOGY
Embryologic Events
• 5th fetal week: Arterial supply to choroid plexus forms from

meninx primitiva
• 7th-8th fetal weeks
Choroid plexus drains via single temporary midline vein
(MPV)
MPV courses posteriorly toward developing
interhemispheric dural plexus (falcine sinus)
• 10th week
ICVs annex drainage of choroid plexus
MPV regresses, caudal remnant unites with developing
ICVs → definitive VofG formed
Image Gallery
Print Images
GRAPHICS
Close-up view of the major deep cerebral veins is
illustrated. The septal and thalamostriate veins come
together to form the internal cerebral veins (ICVs). The
ICVs and basal veins of Rosenthal (BVRs) are the major
tributaries of the vein of Galen. The inferior sagittal sinus
joins the vein of Galen near the apex of the falcotentorial
junction.
Close-up lateral graphic depicts the relationship of the ICV
to adjacent structures (there are 2 ICVs; only 1 is shown
here). The ICV runs posteriorly in the cavum veli interpositi,
which is within the double-layered tela choroidea of the 3rd
ventricle (technically not above it). The ICVs lie above the
pineal gland and body of the 3rd ventricle, below the fornix
and corpus callosum splenium. The BVRs and ICVs unite to
form the vein of Galen.
The deep (subependymal) veins are illustrated here as seen
from the top down. The corpus callosum and fornices have
been removed to show the lateral ventricles. The ICVs
course posteriorly in the velum interpositum, just above the
top of the 3rd ventricle.
Close-up coronal view of the lateral ventricles depicts the
relationship between the medullary (deep white matter) and
subependymal veins. Medullary veins converge at the
ventricular margins, drain into subependymal veins, and
from there into the Galenic system. The ICVs are the most
prominent deep tributaries of the vein of Galen, which is
formed by the junction of the ICVs and BVRs.
LATERAL AND AP ICA DSA

Two lateral DSA views from different patients, midvenous
phase, are shown. The deep white matter (medullary) veins
converge on the ependymal veins, outlining the roof of the
lateral ventricle (seen here as "dots" of contrast).
On the lateral view, venous phase, of this DSA, a long
septal vein joins the thalamostriate and direct lateral veins
well behind the foramen of Monro, a normal variant. The
brush-like linear contrast collections seen near the roof of
the lateral ventricle are the medullary (white matter) veins.
AP view, midvenous phase, of a DSA shows the
thalamostriate vein as it outlines the lateral margin of the
ventricle.
3T AXIAL T1 C+ MR
is shown. Section through the foramen of Monro shows the
septal veins as they curve posteriorly from the frontal horns
around the pillars of the fornix. They join together with the
thalamostriate veins to form the ICVs.
The paired ICVs are seen here as they course posteriorly in
the velum interpositum, above the 3rd ventricle.
Scan through the bodies of the lateral ventricles shows the
enhancing choroid plexus coursing anteriorly along the
striothalamic groove. Choroid veins are the prominent
tortuous vessels running over the choroid plexus.
3T CORONAL T1 C+ MR
Series of 3 coronal T1 C+ scans from posterior to anterior
is shown. Section through the atria of the lateral ventricles
shows the choroid plexus and its veins, as well as the ICVs
coursing posteriorly within the velum interpositum.
Section through the bodies of the lateral ventricles shows
faint enhancement along the superolateral margin of the
ventricle, representing confluence of the deep medullary
(white matter) veins draining into a subependymal vein.
Section just behind the foramen of Monro shows the septal
and thalamostriate veins forming the ICV.
3T CORONAL T2 MR
Series of 6 coronal T2 MR images from posterior to
anterior is shown. Section through the occipital horn of the
lateral ventricle demonstrates confluence of the vein of
Galen with the inferior sagittal sinus at the apex of the
falcotentorial junction.
ICVs are shown just prior to joining the vein of Galen.
BVR and ICVs course posteriorly before anastomosing with
the vein of Galen. The precentral cerebellar vein courses
superiorly in front of the central lobule of the vermis to join
the vein of Galen. Even though it drains posterior fossa
structures, this vein is generally considered part of the so-
called galenic group of veins.
Medial and lateral atrial veins drain into the ICVs. The BVRs
are seen here as they course superomedially around
cerebral peduncles within the ambient and quadrigeminal
cisterns. They will join the ICVs to form the vein of Galen.
The BVRs are actually superficial cerebral veins, although
their drainage pattern is into the deep venous system.
The ICVs are seen here as they course posteriorly within
the velum interpositum, above a cystic pineal gland. The
velum interpositum is a CSF-containing subarachnoid cistern
and is anatomically an anterior extension of the
quadrigeminal cistern. It lies beneath the fornices and above
the 3rd ventricle. Some posterior fossa veins are also seen
in this section.
Scan through the foramen of Monro shows the origin of the
ICVs.
AXIAL CTV
First of 3 axial CT source images from a CT venogram is
shown from inferior to superior. This section shows the
BVRs, posterior aspect of the ICVs, and vein of Galen. The
BVRs, P2 posterior cerebral artery segments, and the
trochlear nerve all course through the ambient cisterns and
are in close proximity to one another.
This view shows the ICVs as they are formed from the
thalamostriate and septal veins. Numerous ventricular
tributaries are present.
This view shows the ICVs, vein of Galen, and straight sinus.
So-called direct lateral veins collect tributaries from the
caudate body as they course along the stria terminalis,
which demarcates the border between the caudate and
thalamus. Sometimes, these veins are quite prominent, as
seen in this case.
CORONAL CTV
First of 3 coronal views of CT venogram from anterior to
posterior with section through the basilar bifurcation shows
a large direct lateral vein draining into the ICV. Its upper
aspect runs along the caudate nucleus; its lower aspect
curves over the thalamus. The stria terminalis is at the
junction of these 2 segments.
The ICVs and both BVRs are seen here just before they
converge to form the vein of Galen. The posterior cerebral
artery lies lateral to the BVRs. Both curve posteriorly
around the midbrain, running in the ambient cistern.
Image at the tentorial apex shows the vein of Galen. The
posterior cerebral artery is seen here, dividing into its
parietooccipital and calcarine arteries.
SAGITTAL CTV
Series of 3 sagittal views of a CT venogram is shown from
medial to lateral. Midline view shows the ICVs as they
follow a sinusoidal course, running posteriorly in the velum
interpositum above the roof of the 3rd ventricle. The vein of
Galen and one of its tributaries, the precentral cerebellar
vein, are well seen here.
Slightly more lateral view shows the choroid plexus of the
lateral ventricle as it courses anteriorly along the
striothalamic groove between the caudate nucleus and
thalamus. This represents the stria terminalis. A so-called
terminal vein, seen here, may course along this groove and
join the caudate and septal veins to form the thalamostriate
vein.
Both the BVR and posterior cerebral artery curve around
the midbrain within the ambient cistern and are seen on this
section.
3D-VRT CTV
Patient-specific 3D CTV was segmented by Drs. Adriene
Eastaway, Michael Bayona, Edward Quigley, edited in
Materialise Mimics, Materialise 3-matic, and cinematically
rendered in Maya with AfterEffects. The calvarium was
rendered translucently with opacity of the skull base for
orientation. The deep venous system with medullary white
matter veins, internal cerebral veins, vein of Galen, and
straight sinus are depicted looking through the cortical veins
and dural venous sinuses.
3T MRV
A series of 3 different projections from a 3T MRV is shown.
The submentovertex view is especially good for evaluating
patency of the major dural venous sinuses, but overlap of
many vessels largely obscures the deep cerebral veins.
Lateral view demonstrates the major deep cerebral veins.
Blood flow from the deep venous system drains into the ICV
before emptying into the vein of Galen. This view is ideal for
evaluating patency of the ICVs, vein of Galen, and straight
sinus. The subependymal and medullary veins are not
generally visualized on standard MRV.
Straight AP view shows that the ICV is superimposed on
the superior sagittal sinus. The thalamostriate vein, well
seen here, defines the outer margin of the lateral ventricle.
A prominent vein of Labbé is present on the left.
3T MIP SWI
Axial MIP view of a T2*SWI sequence shows
deoxyhemoglobin in the deep cerebral veins. Note that the
paired internal cerebral veins are formed by the junction of
the septal and thalamostriate veins. The deep cerebral
veins shown here basically outline the lateral ventricles.
More cephalad MIP SWI through the bodies of the lateral
ventricles nicely demonstrates the medullary veins, which
drain most of the hemispheric white matter and are oriented
perpendicularly to the ventricular ependyma. Deoxygenated
blood in the medullary veins drains into the subependymal
veins of the lateral ventricle, which, in turn, drain into the
thalamostriate veins and are collected by the internal
cerebral veins. Collectively, the deep cerebral veins, basal
veins of Rosenthal (not shown in this series), vein of Galen,
and straight sinus are classified as the galenic system.
More cephalad T2*SWI demonstrates how the deep white
matter (medullary) veins drain into larger subependymal
veins. Medullary veins and the galenic system drain the vast
majority of the deep cerebral white matter and basal
ganglia. Superficial cortical veins drain the cortex and
subcortical white matter.
Selected References
1. Taoka, T, et al. Structure of the medullary veins of the
cerebral hemisphere and related disorders. Radiographics.
2017; 37(1):281–297.
Posterior Fossa Veins
Main Text
T ERM INOLOGY
Abbreviations
• Vein of Galen (VofG)

• Precentral cerebellar vein (PCV)
• Anterior pontomesencephalic vein/venous plexus (APMV)
• Superior vermian vein (SVV)
• Inferior vermian vein (IVV)
• Cerebellopontine angle (CPA)
• Internal auditory canal (IAC)
• Superior petrosal sinus (SPS)
• Subarachnoid space (SAS)
Definitions
• Venous drainage for midbrain, pons, medulla, cerebellum,

vermis
GROSS ANATOMY
Overview
• 3 major posterior fossa/midbrain drainage systems

Superior (galenic) group drains up into VofG, has 3
major named veins
– PCV : Single, midline; lies between lingula/central
lobule of vermis; terminates behind inferior colliculi
by draining into VofG
– SVV : Originates near declive of vermis, courses
up/over top of vermis (culmen), joins PCV and
enters VofG
– APMV : Superficial venous plexus covers cerebral
peduncles, anterior surface of pons
Anterior (petrosal) group
– Petrosal vein: Prominent trunk in CPA that collects
numerous tributaries from cerebellum, pons,
medulla
Posterior (tentorial) group
– IVVs : Paired paramedian structures; curve
posterosuperiorly under pyramis, uvula of vermis
• PCV
Courses over roof of 4th ventricle, anterior (superior)
medullary velum in midline
Lies between lingula, central lobule of vermis
Upper end (at VofG level) lies below, behind
quadrigeminal plate and pineal gland
• SVV
Courses over vermian apex
Lies under tentorium
• APMV
Lies under vertebrobasilar artery
Closely adherent to pial surface of pons
• Petrosal vein
Courses anterolaterally below CNV (trigeminal nerve)
Enters SPS just above IAC
Vascular Territory
• Superior (galenic) group

Midbrain, pons, superior surface of cerebellar
hemispheres, upper vermis
• Anterior (petrosal) group
Anterior (petrosal) surface of cerebellar hemispheres,
lateral pons, brachium pontis, medulla, flocculus,
nodulus
• Posterior (tentorial) group
Inferior/posterior surfaces of cerebellar hemispheres,
inferior vermis, tonsils
IMAGING ANATOMY
Overview
• Superior ("galenic") group

Veins of this group generally course over superior
surfaces of cerebellum, vermis, as well as anterior surface
of midbrain, pons, and medulla
Superior cerebellar veins course over hemispheres
Galenic veins typically drain into VofG or directly into
straight sinus (SS)
Cerebellar hemispheric veins may also drain laterally into
transverse sinus (TS), SPS, or directly into small dural
sinuses within tentorium
• Anterior (petrosal) group
Demarcates middle of CPA cistern
Petrosal vein courses superiorly to drain into SPS
• Posterior (tentorial) group
Demarcates inferior vermis
Normal Imaging
• DSA, lateral view
PCV: Anteriorly convex curve, lies halfway between
tuberculum sellae and torcular Herophili
APMV: Outlines pons, midbrain; lies ~ 1 cm behind
clivus at closest point
SVV: Outlines superior vermis; normally 2-3 mm below
SS
IVV: Outlines inferior vermis; normally at least 1 cm from
inner table of skull
• DSA, AP view
Petrosal vein: May form prominent venous "star" in CPA
cistern
SVVs/IVVs should lie in or near midline
• T1 C+ MR
APMV seen as faint plexiform enhancement along pial
surface of pons, medulla
– Seen on both sagittal, axial scans
• CECT
Axial: Scans cut obliquely through tentorium so superior
cerebellar veins, SVVs appear as linear/serpentine areas
of enhancement
Coronal: May show bridging veins crossing SAS between
cerebellum/vermis, tentorium

Imaging Pitfalls
• APMV enhancement along pontine/medullary surface is

normal; should not be mistaken for meningitis
• Look for/identify superior petrosal vein complex that might
pose risk for intraoperative damage
5% are small, lack visible anastomoses
• Look for/identify intracranial extensions of vertebral venous
plexuses
Image Gallery
Print Images
GRAPHICS
Sagittal graphic with cut through the vermis depicts normal

posterior fossa venous drainage. The superior (galenic)
group drains the upper cerebellum, vermis, and pons. The
anterior (petrosal) group drains the lateral pons,
cerebellum, medulla, and structures in the cerebellopontine
angle cistern. The posterior (tentorial group) drains the
inferior vermis and tentorium.
AP graphic depicts major venous drainage of the pons,

medulla, and anterolateral cerebellum. The anterior
pontomesencephalic vein is actually a plexus of small veins
covering the surface of the pons and medulla. The petrosal
vein and its tributaries provide significant drainage for
structures in the cerebellopontine angle cistern and
anastomose with the lateral mesencephalic vein and
superior petrosal sinus.
LATERAL DSA
Series of 3 lateral views of a vertebrobasilar DSA is shown.

Late arterial/very early venous phase of a lateral DSA
shows a prominent choroid plexus "blush" and early
opacification of the internal cerebral vein, which is a normal
finding on posterior fossa angiograms.
Midvenous phase shows the anterior pontomesencephalic
venous plexus outlining the belly of the pons and
undersurface of the cerebral peduncles. Note numerous tiny
pontine tributaries.
Late venous phase shows prominent suboccipital veins, a
normal finding. The clival venous plexus is opacified and is
shown draining into the jugular vein via the inferior petrosal
sinus. There is faint opacification of the superior sagittal
sinus because the posterior cerebral arteries were
opacified on the arterial phase of this study (not shown).
AP DSA
Series of 3 AP views of a vertebrobasilar DSA is shown.
Early venous phase shows numerous cerebellar
hemispheric and vermian veins, as well as cortical veins of
the occipital lobe (the posterior cerebral arteries were
opacified on earlier arterial phase, not shown here). Note
significant asymmetry between the sigmoid sinuses and
jugular bulbs, which is a normal variant.
Midvenous phase shows the petrosal veins draining into the
superior petrosal sinuses, which, in turn, drain into the
transverse sinuses. Note that the superior sagittal sinus
deviates from the midline as it descends toward the right
transverse sinus, which is a normal variant.
Late venous phase shows opacification of very prominent
suboccipital veins on the right, which is a normal finding.
3T AXIAL T1 C+ MR
Series of 6 axial T1 C+ fat-saturated MR scans through the
posterior fossa is shown. Section through the foramen
magnum shows the clival venous plexus and a striking
marginal venous plexus around the rim of the foramen
magnum. An inconstant dural sinus, the occipital sinus, may
connect the marginal plexus with the torcular Herophili.
Inhomogeneous signal within the internal jugular vein, as
seen on this scan, is a normal finding.
Section through the jugular bulbs demonstrates the typical,
normal, side-to-side asymmetry and inhomogeneous
enhancement. The enhancing structures medial to the bulbs
are venous plexi that accompany CNXII as it passes
through the hypoglossal canal.
Scan through the lateral recesses of the 4th ventricle shows
the inferior petrosal sinuses especially well. The inferior
petrosal sinus connects the clival venous plexus with the
jugular bulb.
Section through the upper petrous ridges shows the right
superior petrosal sinus. A hypoplastic vein of Labbé is
present. The prominent venous structures in the
cerebellopontine angle cistern are petrosal veins.
Scan through the upper pons shows prominent petrosal
veins bilaterally with numerous tributaries within the
cerebellopontine angle cistern. The faint enhancement
covering the pial surface of the pons is the anterior
pontomesencephalic venous plexus and is a normal finding
that should not be mistaken for meningitis.
Scan through the upper cerebellum and midbrain shows
very prominent tentorial veins that drain into the transverse
sinuses.
Selected References
1. Bender, B, et al. Depiction of the superior petrosal vein
complex by 3D contrast-enhanced MR angiography. AJNR
Am J Neuroradiol. 2018; 39(12):2249–2255.
2. Tubbs, RS, et al. Intracranial connections of the vertebral
venous plexus: anatomical study with application to
neurosurgical and endovascular procedures at the
craniocervical junction. Oper Neurosurg (Hagerstown). 2018;
14(1):51–57.
Extracranial Veins
Main Text
T ERM INOLOGY
Abbreviations

• Common carotid artery (CCA)
• Inferior, superior ophthalmic veins (IOV, SOV)
Definitions
• Extracranial veins include scalp, skull (diploic), face, neck

veins
GROSS ANATOMY
Overview
• Scalp veins connect via emissary veins to cranial dural

sinuses
Superficial temporal vein collects numerous scalp,
auricular tributaries
– Descends into parotid space
– Together with maxillary vein forms retromandibular
vein
• Diploic veins
Large, irregular endothelial-lined channels in diploic
spaces of calvarium
May form large venous "lakes"
Connect freely with dural sinuses, meningeal veins
• Emissary veins connect intra- and extracranial veins
Traverse cranial apertures, foramina
Connect venous sinuses, extracranial veins
Highly variable
• Orbital veins (2 major)
SOV connects face/orbit with CS
IOV is smaller, less conspicuous
• Facial veins
Facial vein
– Begins at angle between eye, nose
– Descends across masseter, curves around mandible
– Joins IJV at hyoid level
– Tributaries from orbit (supraorbital, superior
ophthalmic veins), lips, jaw, facial muscles
Deep facial vein
– Receives tributaries from deep face; connects facial
vein with pterygoid plexus
Pterygoid plexus
– Network of vascular channels in masticator space
between temporalis/lateral pterygoid muscles
– Connects CS, clival venous plexus with face/orbit
tributaries
– Drains into maxillary vein
Retromandibular vein
– Formed from union of maxillary, superficial temporal
veins
– Lies within parotid space
– Passes between external carotid artery (ECA) and
CNVII to empty into external jugular vein
• Neck veins
External jugular vein
– From retromandibular, posterior auricular veins
– Receives tributaries from scalp, ear, face
– Size, extent highly variable
IJV
– Caudal continuation of sigmoid sinus
– Jugular bulb = dilatation at origin
– Courses inferiorly in carotid space posterolateral to
ICA, CCA
– Unites with subclavian vein to form brachiocephalic
vein
– Size highly variable; significant side-to-side
asymmetry common
Vertebral venous plexus
– Suboccipital venous plexus
– Tributaries from basilar (clival) plexus, cervical
musculature
– Interconnects with sigmoid sinuses, cervical epidural
venous plexus
– Terminates in brachiocephalic vein
IMAGING ANATOMY
Overview
• Extracranial veins highly variable, inconstantly visualized on

DSA/CTA/MRA
Scalp, emissary veins
– Rarely opacified on normal DSA but often seen on
fat-saturated T1 C+ MRs
– May become prominent if dural arteriovenous
fistula, dural sinus occlusion, sinus pericranii
present
Orbital veins
– Flow in SOV is normally from extra - to intracranial
– Rarely prominent at DSA unless vascular
malformation (e.g., C-C fistula) or CS occlusion
present (flow reverses)
Face, neck veins
– Inconstantly visualized
– Pterygoid plexus often prominent on both DSA, T1
C+ MR scans
Variations, Anomalies
• Extracranial venous drainage highly variable

• Sinus pericranii
Abnormal communication between dural venous sinus,
extracranial veins
Seen as vascular scalp mass that communicates with
dural sinus via transcalvarial vein (through well-defined
bone defect)
Association with intracranial developmental venous
anomaly common (± venous varix)

Imaging Pitfalls
• Diploic veins, venous "lakes" ("lacunae") may form sharply

marginated, well-corticated skull lucencies (do not mistake
for metastases or myeloma)
• Prominent, persistent SOV opacification on DSA is nearly
always abnormal but normal on CECT, enhanced MR
• Asymmetric IJVs are common; 1 IJV may be many times size
of contralateral IJV
• Extracranial venous plexuses (pterygoid, suboccipital) can
normally be very prominent
Image Gallery
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GRAPHICS
Anteroposterior view of the extracranial venous system

depicts the major neck veins, their drainage into the
mediastinum, and their numerous interconnections with the
intracranial venous system. The pterygoid venous plexus
receives tributaries from the cavernous sinus and provides
an important potential source of collateral venous drainage
if the transverse or sigmoid sinuses become occluded.
Sagittal graphic depicts the major extracranial veins of the

scalp, face, and neck. Significant tributaries are also shown.
Numerous anastomoses between the intra- and extracranial
veins provide a potential collateral pathway for venous
drainage if a major dural sinus becomes thrombosed. Note
collateral drainage from the cavernous sinus anteriorly
(through the superior and inferior ophthalmic veins to the
facial vein) as well as inferiorly (through basilar foramina to
the pterygoid venous plexus) and posteriorly (through the
superior and inferior petrosal sinuses). The internal and
external jugular veins also have significant interconnections.
The deep vertebral venous plexus with its intra- and
extraspinal anastomoses is not shown in this graphic.
SAGITTAL CECT
Series of 2 reconstructed sagittal views from a thin-section

axial CECT scan shows the internal jugular vein (IJV) and its
relationship to the skull base. Note the proximity of the IJV
and jugular bulb to the petrous temporal bone and internal
carotid artery (ICA). The IJV descends inferiorly within the
carotid space.
IJVs vary significantly in size. Significant side-to-side

asymmetry is common. This IJV is average in size and
configuration.
CORONAL CECT
A series of 2 coronal views from a thin-section CECT scan
of the neck show the IJVs and some tributaries that arise
near the skull base. This view shows significant side-to-side
asymmetry of the 2 IJVs, a common normal variant.
Extensive interconnections between the intra- and
extracranial venous systems are normally present. The
hypoglossal venous plexus, petrosal sinuses, clival venous
plexus, cavernous sinus, and pterygoid plexus are
extensively interconnected.
3T AXIAL T1 C+ MR
A series of 6 axial T1 C+ MR scans are shown from inferior
to superior. The upper cervical epidural venous plexus is
seen on this section. Vessels within the carotid space are
well delineated. The cervical ICA lies anteromedial to the
IJV in this space.
Section through the foramen magnum shows the
interconnections between the lower clival, upper cervical
epidural, and suboccipital venous plexi. Condylar emissary
veins also connect the intra- and extracranial veins around
the foramen magnum and upper cervical spinal canal.
A more inferior section through the upper part of the
extracranial IJVs shows the inhomogeneous signal caused
by spin dephasing. Unusually large condylar emissary veins
are present, connecting with the suboccipital veins.
Scans continue superiorly. Section through the medulla, just
above the foramen magnum, shows the hypoglossal venous
plexus and its interconnections with the clival venous plexus
and large condylar emissary veins. Note asymmetry of the
jugular bulbs at this level, a common normal variant.
Section through the inferior clivus at the level of the
hypoglossal canals shows prominent venous plexi traversing
the hypoglossal canals. Note interconnections between the
clival venous plexus and extracranial IJV via the hypoglossal
venous plexi.
This scan shows the jugular bulbs nicely.
3T CORONAL T1 C+ MR
A series of 6 coronal fat-saturated T1 C+ MR scans from
posterior to anterior demonstrate the numerous
anastomoses between the posterior fossa dural venous
sinuses and the extensive venous plexi that surround the
upper cervical spine. These interconnections may provide a
source for collateral venous drainage if the jugular vein
becomes occluded.
Section through the cervicomedullary junction demonstrates
prominent veins in and around the spine and posterior skull
base.
Section through the middle of the upper cervical spine and
foramen magnum nicely demonstrates the numerous
interconnections between prominent suboccipital veins,
vertebral venous plexus, and epidural venous plexus.
This section is more anteriorly directly through the jugular
foramen. Note intensely enhancing IJV seen superolateral to
the occipital condyles. The jugular tubercles and occipital
condyles together resemble the outline of 2 eagles. The
head of the eagle (jugular tubercle) separates the internal
jugular bulb and vein from the hypoglossal canal and its
venous plexus, nicely seen here.
Scan just anterior to the IJVs shows the ICA running
cephalad within the carotid space. The ICA lies
anteromedial to the IJV.
Scan through the mandibular condyles and lower clivus
shows prominent enhancing veins under the skull base
within the pterygoid muscles. These constitute the pterygoid
venous plexus, which is usually opacified on T1 C+ MR
scans of the neck.
GRAPHIC & AXIAL CECT

Graphic and accompanying axial CECT scans depict the
venous structures within the midneck. The IJV lies
posterolateral to the carotid artery within the carotid space.
Axial CECT depicts the neck vessels at the C1 level.
This image depicts the neck vessels at the level of the hyoid
bone.
PA R T I I
Spine
Outline

SECT ION 1
VERTEBRAL COLUMN, DISCS, AND
PARASPINAL MUSCLE
Outline

Vertebral Column Overview
Main Text
T ERM INOLOGY
Abbreviations
• C1 (atlas), C2 (axis)
• Atlantooccipital (AO)
• Anterior, posterior longitudinal ligaments (ALL, PLL)
GROSS ANATOMY
Overview
• Normally 33 spinal vertebrae (varies from 32-35)

7 cervical (most constant); 12 thoracic; 5 lumbar
5 sacral elements fuse → sacrum
4-5 coccygeal elements → coccyx (most variable)
• Classic anatomic division into anterior (vertebral body),
posterior elements (neural arch)
• "3 columns" concept (used by spine surgeons)
Anterior column
– Anterior 1/2 of vertebral body/disc/annulus
– ALL
Middle column
– Posterior 1/2 of vertebral body/disc/annulus
– PLL
Posterior column
– Posterior elements (pedicles, facet joints, laminae,
spinous processes)
– Ligamentum flavum
– Interconnecting ligaments (interspinous, etc.)
Components
• Bones
Body : Cylindrical ventral bone mass
Arch : Composed of 2 pedicles, 2 laminae, 7 processes (1
spinous, 2 transverse, 4 articular)
– Pedicles: Extend from dorsolateral body to unite with
pair of arched, flat laminae
– Laminae: Arch over canal, join at midline to dorsal
projection (spinous process)
– Transverse processes: Arise from sides of arch
– Articular processes: Each has superior process (with
facet directed dorsally), inferior process (facet
directed ventrally), pars interarticularis (between
facets)
• Intervertebral disc
Composed of inner nucleus pulposus, outer annulus
fibrosus
Adhere to hyaline cartilage of vertebral endplates
Avascular (except in young children and peripheral
annular fibers in adults)
• Ligaments
ALL
– Fibrous band along entire ventral surface of spine
– Skull to sacrum
PLL
– Dorsal surface of vertebral bodies
– Skull to sacrum
Craniocervical ligaments
Interspinous ligaments
• Nerves (31 pairs)
8 cervical, 12 thoracic
5 lumbar (exit above disc, below pedicle)
5 sacral, 1 coccygeal
• Meninges
Single (meningeal) layer of dura
Arachnoid (continuous with cranial arachnoid, loosely
adherent to dura)
Pia (covers spinal cord, nerves)
• Vasculature
Arteries: Segmental arteries arise as dorsal rami from
vertebral, subclavian, intercostal arteries
Veins: Y-shaped basivertebral veins connect with
valveless epidural venous plexus; extensive anastomoses
with cavae, azygos/hemiazygos systems
IMAGING ANATOMY
Overview
• MR
Body: Signal intensity of marrow varies with age
– Hemopoietic ("red") marrow is hypointense on
T1WI, becomes hyperintense with conversion from
red → yellow (age 8-12 years)
– End-plate, reactive marrow changes normally with
aging (can be fibrovascular, fatty, or sclerotic)
Intervertebral disc: Signal intensity varies with age
– Hyperintense on T2WI in children, young adults;
progressive ↓ water → hypointense on T2WI
– Disc degeneration, dessication, shape change (bulge)
normal after 2nd decade
Ligaments: Hypointense on both T1WI and T2WI
Nerves: No enhancement until reach dorsal root ganglia,
where they loose blood-nerve barrier
Meninges: Dura, basi-/epidural veins enhance

• CT: Use both bone, soft tissue algorithms; sagittal, coronal

reconstructions helpful
• MR: Use STIR, fat-sat T1 C+ scans for marrow disorders
Standard planes = axial/sagittal but coronal useful in
elderly, scoliotic patients
Obtain axial scans through discs using coronal localizer
for scoliotic patients
Imaging Pitfalls
• Classic number (7-12-5-5-4) found in only 20%

• Foci of T1 hyperintensity (focal fatty marrow deposits,
incidental hemangiomas) are common and normal
• Vertebral marrow in middle-aged, elderly patients may
appear very inhomogeneous
EMBRYOLOGY
Embryologic Events
• Cranial 1/2 of C1, occipital sclerotomes combine → occiput

C1 exits below occiput, above C1 ring
• Lower 1/2 of upper, upper 1/2 of lower sclerotomes combine
→ vertebral bodies
C8 exits below lowest cervical vertebra (C7)
All thoracic and lumbar nerves arise below their
respective pedicles
Image Gallery
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GRAPHICS
Sagittal midline graphic of the adult spine with soft tissues

removed provides a nice overview of vertebral column. Note
3 curvatures: Cervical (lordosis) is the least marked.
Thoracic curve is a kyphosis. The lumbar lordosis extends
from T12 to the lumbosacral junction, with the most
convexity in its caudal 3 segments. Most vertebrae, except
for the specialized C1, C2, and sacrococcygeal segments,
have a larger ventral body and thinner posterior neural arch.
Generally, the vertebral bodies increase in width from C2-
L3, reflecting their increased load-bearing function. Pedicles
attach the neural arches to the vertebral bodies. The
vertebral canal extends from the foramen magnum to the
sacrum, varying in diameter with the largest dimension
generally at the thoracolumbar junction. Note spinous
process in thoracic area overlap like shingles on a roof.
SAGITTAL T2 MR
Sagittal T2 MR of the entire spine shows the general
morphology of the spinal canal and spinal cord. The cord
follows the gentle, undulating course of the 2 upper spinal
curves to end at the conus medullaris around the L1 level.
The multiple roots of the cauda equina descend from the
distal cord to their exiting foramen in the lumbar and sacral
spines.
GRAPHICS
Coronal graphic of the spinal column as a whole shows

relationship of the 7 cervical, 12 thoracic, 5 lumbar, 5 fused
sacral, and 4 coccygeal bodies. Note cervical bodies are
smaller with neural foramina oriented at 45° and capped by
the unique C1 and C2 morphology. Thoracic bodies are
heart-shaped with thinner intervertebral discs and are
stabilized by the rib cage. Lumbar bodies are more
massive, with prominent transverse processes and thick
intervertebral discs. Sacrum shows a unique morphology
with fusion of multiple segments forming a triangular bone
mass.
Coronal graphic demonstrates spinal nerve roots as they

exit above the intervertebral disc spaces, just under the
pedicles. C1 exits between the occiput and C1, while C8
exits at the C7-T1 level. Thoracic and lumbar roots exit
below their respective pedicles.
3D-VRT NECT
Anterior 3D-VRT NECT of the spine shows the relationships

of the cervicothoracic junction, thoracic, lumbar, and sacral
spine. The strong costotransverse and costovertebral joints
provide stabilization for the long thoracic column and limit
rotation. The lumbar intervertebral discs are thick and
separately defined on this reconstruction. The thinner
thoracic intervertebral discs are poorly defined.
Oblique 3D-VRT NECT, from behind and slightly to the left,

demonstrates the relationship of the ribs to the transverse
processes especially well. Thoracic transverse processes
project laterally from the pediculolaminar junctions. Note
that thoracic spinous processes overlap each other,
especially from T5-8.
3D-VRT NECT AND SAGITTAL CT

Sagittal 3D-VRT NECT shows the balancing set of 4 spinal
curves. The 2 primary flexed segments present at birth are
the thoracic and sacral, with the secondarily developing
lordotic curves occurring in the cervical and lumbar spinal
segments.
Sagittal reformat CT shows overall vertebral body and
spinal canal morphology. The cranium rests upon the
lordotic curves of the cervical spine, with their smaller
bodies and prominent spinous processes. Note the flexed
posture of the thoracic spine with characteristic long,
oblique, inferiorly directed spinous processes extending
over the body level below. The lumbar lordosis with large
bodies and posterior elements provides a platform for large
muscle attachment.
CORONAL NECT
First of 4 coronal reformatted CT images shows the dorsal
aspects of the spinal column. Spinous processes are seen
as ovoid, bony, corticated densities, with the symmetrical
costovertebral joints surrounding each posterior element.
The more anterior section through the lumbar regions shows
the junction of the spinous process with the lamina and the
lumbar facet joints.
Section more anteriorly shows the appearance of the
laminae and costotransverse joints that lie superolateral to
the laminae. Inferiorly, the lumbar region demonstrates the
facet joints and the opposed superior and inferior articular
processes.
Image through the pedicles shows the width of the bony
spinal canal in the thoracic and lumbar segments. The
medial rib heads and pedicles are seen as paired ovoid,
bony densities on either side of midline. The transition to the
lumbar spine is defined by the lack of medial rib component
and a large, horizontally directed transverse process.
Image through the mid vertebral body level shows the
rectangular-shaped bodies of the thoracic and lumbar
segments. The costovertebral joints are present in the
thoracic spine, centered at the disc levels since they attach
to 2 adjacent vertebral bodies with demifacets. The thick
and stout lumbar bodies are seen atop the triangular-
shaped sacrum with the ventral-directed sacral neural
foramina.
Ossification
Main Text
GROSS ANATOM Y
Overview
• Primary (1°) ossification center

Primary focus of spinal ossification
At site of blood vessel invasion of future vertebrae
cartilaginous model
Present at birth
• Secondary (2°) ossification center
Secondary focus of spinal ossification
Appears around puberty
• Ring (an n ular) apophysis
2° ossification of superior/inferior centrum edges
Separated from remainder of vertebral body by thin
hyaline cartilage rim
Appears between 6-8 years (girls) and 7-9 years (boys)
Coalesces by ~ 21 years into single ring
Fusion with vertebral body (14-21 years) → longitudinal
growth stops
• Synchondrosis
Cartilaginous junction between nonmobile vertebral
articulating surfaces
Neurocentral suture = synchondrosis between vertebral
centrum, neural arches
IMAGING ANATOMY
Overview
• General ossification patterns

Centrum ossification
– Starts at lower thoracic/upper lumbar spine of fetus
– Moves in both cranial, caudal directions
Neural arch ossification
– Begins at cervicothoracic level → upper cervical →
thoracolumbar
At birth most vertebrae have three 1° and five 2°
ossification centers connected by hyaline synchondroses
Exceptions to typical ossification occur at C1, C2, C7,
lumbar vertebra, sacrum, coccyx
• Atlas (C1)
2-5 (3 most common) 1° ossification centers
– Anterior arch (1), posterior arch (1) + lateral masses
(2)
No 2° ossification centers
• Axis (C2)
Five 1° ossification centers
– Centrum (1), posterior vertebral neural arch (2),
odontoid process (2)
– Dens separated from C2 centrum by remnant of
embryonic C1-C2 disc
Two 2° ossification centers
– Inferior annular epiphysis, apex of odontoid
• C3-C6
Three 1° ossification centers per each vertebra
– Centrum (1), posterior vertebral neural arch (2)
Five 2° ossification centers per each vertebra
– Spinous process apex (1), transverse process apex
(2), annular epiphysis (2)
• C7
Same 1°/2° ossification centers as C3-C6
– Plus 1° ossification centers for 2 costal processes
– These appear by 6 months of age
– Fuse with transverse process, vertebral body by 5-6
years
– If remain unfused → cervical ribs (1%)
• Thoracic (T1-T12)
Three 1° ossification centers per vertebra
Five 2° ossification centers per vertebra
(2), annular epiphysis (2)
• Lumbar (L1-L5)
Three 1° ossification centers per vertebra
Seven 2° ossification centers per vertebra,
(2), annular epiphysis (2), base of mammillary
processes (2)
• Sacrum (S1-S5)
Five 1° ossification centers per vertebra
– Centrum (1), posterior neural arch (2), costal
element remnants (2)
Four 2° ossification centers
– Sacroiliac joint epiphyseal plates (fuse ~ 25 years)
• Coccyx (Co1-Co4)
Co1 has three 1° ossification centers: Centrum (1),
cornua (2)
Co2-Co4 have one 1° ossification center each
Co1 ossifies shortly following birth; remaining coccygeal
vertebra ossify into 3rd decade
No 2° ossification centers
Questions
• Centrum smaller than adult vertebral body

Centrum → central vertebral body
Anterior extent of neural arch → posterolateral vertebral
body
• Progression of synchondrosis closure important for imaging
interpretation
C1
– Anterior C1 arch: 8-12 months
– Posterior C1 arch: 1-7 years
– C1 lateral masses: 7-9 years
C2
– Odontoid: C2 body: 3-7 years
– Superior odontoid center appears ~ 2-6 years, fuses ~
11-12 years
– Posterior C2 synchondrosis: 4-7 years
Below C2
– Neurocentral synchondrosis closes ~ 3-7 years;
posterior synchondrosis ~ 4-7 years
Imaging Pitfalls
• Symmetry, location, corticated margins, patient age help

distinguish open synchondrosis from fracture
• Cervical vs. thoracic ribs: Transverse processes oriented
inferiorly in cervical, superiorly in thoracic spine
• Immature ossification results in focal vertebral weaknesses
at cartilage: Pediatric-specific fractures, such as ring
apophysis and odontoid synchondrosis fractures
Image Gallery
Print Images
GRAPHICS
Axial graphic of the atlas (C1) in a skeletally immature child,

seen from above, depicts the most common configuration of
anterior and posterior arch primary ossification centers,
joined by cartilaginous synchondroses (shown in blue). The
transverse foramen contains the vertebral artery and
vertebral veins.
Coronal graphic of the axis (C2) in a skeletally immature
child, viewed from in front, depicts the five 1° ossification
centers (centrum, neural arches, odontoid processes) and
two 2° ossification centers (odontoid tip, inferior annular
epiphysis) arising within the cartilaginous model (shown in
blue).
Axial graphic of a skeletally immature child, shown from
above, depicts a stylized typical lumbar vertebra with 3
primary ossification centers (including the centrum) and 2
posterior neural arches separated by cartilaginous
synchondroses.
Graphic representation of a typical lumbar vertebral body
depicts the relationship of the centrum to the cartilaginous
(shown in blue) endplate and annular (ring) apophyses. The
superior and inferior annular epiphyses are 2° ossification
centers (fuse at puberty).
Coronal graphic of the infant sacrum, seen from in front,
depicts ossification in the sacral centrum and lateral costal
element remnant 1° ossification centers. The majority of the
sacrum and entire coccyx is cartilaginous (shown in blue) at
this stage in development.
Axial graphic representation of the sacrum in an older child,
seen from above, depicts the five 1° ossification centers
(centrum, 2 posterior arches, 2 costal elements remnants)
connected by cartilaginous synchondroses (shown in blue).
The sacral sacroiliac joint epiphyseal plates (2° ossification
centers) fuse at ~ 25 years.
GRAPHICS
Sagittal graphic depicts cervical vertebral bodies and
intervertebral discs of a 6-year-old male patient. Centrums
of the disc are ossified at this age and contain hemopoietic
("red") marrow. Nonossified annular epiphyses surround the
bodies and spinous processes. The nonossified epiphyses
plus the intervertebral discs account for the wide
intervertebral distance between the ossified centrums seen
on imaging studies at this age. The odontoid tip persists as
a separate 2° ossification center.
Sagittal midline graphic depicts lumbar vertebral bodies,
intervertebral discs, and sacrum of a 6-year-old male
patient. As in the cervical spine, the centers of the vertebral
bodies and spinous processes are ossified at this age and
contain hemopoietic ("red") marrow. The intervertebral
distances between the ossified centra are even more
prominent in the lumbar spine.
AXIAL BONE CT, ATLAS (C1) VERTEBRA

Axial bone CT of a 2-week-old female patient demonstrates
the 3 atlas 1° ossification centers. Much of the atlas is
unossified cartilage at this age. The odontoid process
ossification centers (C2) are identified posterior to the C1
anterior arch.
Composite image from 2 contiguous axial bone CT images
of C1 of a 14-month-old male patient shows further
development of the three 1° ossification centers. The
synchondroses between the centrum and posterior neural
arches are smaller.
Axial bone CT of the atlas of a 6-year-old female patient
shows fusion of the anterior and posterior neural arch 1°
ossification centers to form a complete C1 ring. Note that
the two C2 odontoid process 1° ossification centers show
residual sclerotic line at the synchondrosis.
AXIAL BONE CT, AXIS (C2) VERTEBRA

the 3 axis 1° ossification centers separated by
synchondroses.
Axial bone CT of a 4-year-old male patient demonstrates
progressive ossification of the 3 axis 1° ossification centers.
Note that the centrum comprises only the central vertebral
body, while the anterior portion of the neural arches form
the lateral vertebral body. The posterior arch synchondrosis
is fused.
Axial bone CT of a 10-year-old male patient shows fusion of
the 1° ossification centers by closure of the neurocentral
synchondroses. Sclerosis at the dens base indicates
ossification within the rudimentary C1-C2 intervertebral disc
remnant joining the odontoid process to the C2 centrum.
CORONAL BONE CT, AXIS (C2) VERTEBRA

Coronal bone CT of the upper cervical spine of a 2-week-
old female patient shows the 3 cervical vertebra 1°
ossification centers and two 1° odontoid ossification
centers. The dens tip is cartilaginous at this developmental
stage.
Coronal bone CT of the cervical spine of a 4-year-old male
patient shows progressive ossification of the centrum and
neural arches connected by thin synchondroses. The
characteristic location, symmetry, and well-corticated
margins of the synchondroses helps distinguish them from
fracture. Note that the ossified odontoid tip 2° ossification
center is now visible.
Coronal bone CT of a 10-year-old male patient shows
fusion of the synchondroses. The C1-C2 intervertebral disc
remnant separating the dens from the C2 centrum remains
visible as a sclerotic line.
AXIAL & SAGITTAL BONE C T, C ERVIC AL (C 3-C 6)

VERTEBRA
Axial bone CT of C5 of a 2-week-old female patient
demonstrates neurocentral synchondroses and
synchondrosis junction of the neural arches. Note that the
lateral vertebral body arises from the neural arches.
Sagittal bone CT of a 6-year-old male patient demonstrates
the normal appearance of the midcervical vertebra. The
wide intervertebral distance between the ossified centrums
represents the intervertebral discs and nonossified annular
epiphysis 2° ossification centers. There is normal sclerosis
at the fusion of the odontoid process to the C2 centrum.
The odontoid tip persists as a separate 2° ossification
center.
Axial bone CT of a midcervical vertebra of a 6-year-old
female patient shows complete synchondrosis fusion with
only a faint sclerotic line visible at the site of the fused
neurocentral synchondroses.
AXIAL BONE CT, C7 VERTEBRA

the normal appearance of C7. The transverse processes
are characteristically longer than the other cervical vertebra,
assisting identification of C7.
Axial bone CT of a 4-year-old male patient demonstrates
posterior fusion of the neural arches. The neurocentral
synchondrosis is faintly apparent. The transverse process
tip 2° ossification centers are visible.
Axial bone CT of a 6-year-old female patient shows
synchondrosis fusion between the centrum and posterior
neural arches. The synchondrosis between the transverse
process tip 2° ossification center and neural arch transverse
process remains open (normally closes at puberty).
AXIAL BONE CT, THORACIC VERTEBRA

Axial bone CT of a 3-day-old male patient demonstrates the
three 1° ossification centers + synchondroses seen in a
typical thoracic vertebra.
Axial bone CT of a 2-year-old female patient shows
narrowing of the neurocentral synchondroses and
enlargement of the ossified centrum. The rib 2° ossification
centers have not yet appeared.
Axial bone CT of a 13-year-old male patient shows fusion of
the neurocentral and transverse process 2° ossification
center synchondroses. The rib head 2° ossification centers
are now ossified.
AXIAL BONE CT, LUMBAR VERTEBRA

Axial bone CT of a 4-day-old male patient demonstrates the
three 1° vertebral ossification centers and synchondroses in
a typical lumbar vertebra.
Axial bone CT of L1 of a 2-year-old male patient shows
maturational development of the 1° ossification centers and
neurocentral synchondroses. The transverse process 2°
centers are not yet ossified.
Axial bone CT of L2 of a 13-year-old male patient shows
completed fusion of the 1° synchondroses. The transverse
process 2° ossification centers are ossified but not yet
fused to the transverse processes.
AXIAL BONE CT, SACRUM

Axial bone CT of S2 of a 3-day-old female patient shows
the five 1° ossification centers (centrum, costal element
remnants, neural arches) present at birth, separated by
synchondroses. Both the S1 and S2 centrums are visible in
this single slice because of the oblique angulation of the
sacrum relative to the axial CT slice.
Axial bone CT of the sacrum of a 2-year-old male patient
shows typical configuration of the five 1° sacral ossification
centers. The sacroiliac joints appear widened because the
SI joint epiphyseal plates are not yet ossified.
Axial bone CT of the sacrum of a 16-year-old female patient
demonstrates closure of the synchondroses and completed
ossification of the 1° and 2° ossification centers. The site of
the synchondroses persist as faint sclerotic lines.
SAGITTAL BONE CT, COCCYX

Sagittal bone CT of the sacrum and coccyx of a 24-month-
old female patient demonstrates ossification of the 5 sacral
vertebra. The first 3 coccygeal vertebra show ossification in
the primary ossification centers only. The underlying
cartilaginous model is visible as soft tissue density
containing the ossified centrums.
Sagittal bone CT of the sacrum and coccyx of a 16-year-old
female patient is shown. Note the more mature appearance
of the 5 sacral vertebra and first 3 coccygeal vertebra.
SAGITTAL T1 MR
Sagittal T1 MR in 4-day-old infant shows the characteristic
appearance of vertebrae and intervening disc. The central
vertebral ossification center is markedly hypointense and
contains a linear horizontal hyperintense cleft from the
developing basivertebral venous plexus. The very prominent
cartilaginous endplates are hyperintense and separated by
hypointense disc.
Sagittal T1 MR in 5-month-old infant shows gradual
increasing signal within the ovoid vertebral ossification
center and decreasing prominence of the hyperintense
cartilage endplates.
Sagittal T1 MR in 1-year-old infant shows continued
increasing signal within the vertebral ossification center,
which now has a more rectangular shape. The cartilage
endplates are less prominent and have continued decreased
signal relative to the vertebral ossification center.
SAGITTAL T2 MR
Corresponding sagittal T2 MR in the same 4-day-old infant
shows very hypointense central ossification centers, mildly
hyperintense cartilage endplates, and hyperintense
intervertebral discs.
Corresponding sagittal T2 MR in the same 5-month-old
infant shows increasing signal within the central vertebral
body, which are now isointense with the endplates.
Corresponding sagittal T2 MR in the same 1-year-old infant
shows similar increasing signal within the central vertebral
body with corticated hypointense margins. The
intervertebral disc remains hyperintense.
Vertebral Body and Ligaments
Main Text
T ERM INOLOGY
Abbreviations
• Anterior, posterior longitudinal ligaments (ALL, PLL)
GROSS ANATOMY
Overview
• Vertebral body
Varies in size, shape depending on region
Generally ↑ size from cervical to lumbar, then ↓ from
sacrum to coccyx
• Cervical : Upper 7 vertebrae
C1 (atlas) : No body, spinous process; circular shape
– Anterior, posterior arches; 2 lateral masses;
transverse processes
C2 (axis) : Body with bony peg (dens/odontoid process)
– Large, flat ovoid articular facets
– Broad pedicles, thick laminae
– Transverse processes contain L-shaped foramina for
vertebral artery (VA)
C3-C6 similar in size, shape
– Bodies small, thin relative to size of arch
– Transverse diameter > AP; triangular central canal
– Lateral edges of superior surface turn upward, form
uncinate processes
– Pedicles short, small, directed posterolaterally
– Lateral masses rhomboid-shaped with slanted
superior/inferior articular surfaces
– Transverse processes contain transverse foramina for
VAs
– C3-C5 spinous processes usually short, bifid
C7 marked by longest spinous process
• Thoracic
Bodies heart-shaped, central canal round
Pedicles short, directed posteriorly
Laminae broad/thick
Spinous processes point caudally, dorsally
Superior articular processes vertical, flat, face posteriorly
T12 resembles upper lumbar bodies with inferior facet
directed more laterally
Costal articular facets on body/transverse processes
– Articulate with heads of ribs
– T1 has complete facet for 1st rib, inferior demifacet
for 2nd rib
• Lumbar
Body large, wide, thick
Pedicles strong, thick, directed posteriorly
Laminae strong, broad
Superior articular processes face dorsomedial
Inferior articular processes face anterolateral
• Sacrum : Fusion of 5 segments
Large, triangular-shaped bone with base, apex, 3 surfaces
(pelvic, dorsal, lateral), 2 alae
Base: Round/ovoid; articulates with L5
Pelvic surface
– Anterior sacral foramina at lateral ends of ridges
– Concave, crossed by 4 transverse ridges
Posterior surface
– Median sacral crest in midline
– Sacral groove on either side of crest
– Intermediate crest lateral to sacral groove
– Posterior sacral foramina lateral to crest
– Lateral crest is lateral to sacral foramina
Lateral surface: Formed by costal, transverse processes
– Alae on sides articulate with iliac bone
Apex: Inferior aspect of S5, articulates with coccyx
• Coccyx : Fusion of 3-5 segments
Anterior surface concave with transverse ridges
Posterior surface convex with transverse ridges
Apex round, directed caudally, may be bifid
• Ligaments
ALL : Fibrous band on ventral surface of spine from skull
to sacrum
– Firmly attached at ends of each vertebral body
– Loosely attached at midsection of disc
– 3 sets of fibers: Deep span 1 disc; intermediate 2-3
discs; superficial 4-5 levels
PLL : Dorsal surface of bodies from skull to sacrum
– Attached at discs, margins of vertebral bodies
– Cervical/thoracic: Broad, uniform
– Lumbar: Narrow at body, broad at disc level
Ligamentum flavum
– Largest elastic ligament in body
– Connects adjacent lamina from C2 to lumbosacral
junction
– Extends from capsule of apophyseal joint to junction
of lamina with spinous process
– Thin, broad in cervical region, thicker in lumbar
Intertransverse ligaments : Extend between transverse
processes
– Cervical: Sparse or absent
– Thoracic: Stronger associated with muscles
Interspinous ligaments : Connect adjoining spinous
processes
– Between ligamentum flavum, supraspinous
ligaments
– Strongest in lumbar spine
Supraspinous ligaments : Extend from tips of spinous
processes from C7 to sacrum
– Fused with dorsal margin of interspinous ligament
– Broader, thicker in lumbar spine
– Merges with ligamentum nuchae in cervical spine
– Ligamentum nuchae extends from external occipital
protuberance to C7
IMAGING ANATOMY
Overview
• Transitional lumbosacral bodies (up to 25% in normal)

Sacralization of lumbar body: Spectrum extending from
expanded transverse processes of L5 articulating with
top of sacrum to incorporation of L5 into sacrum
Lumbarization of sacrum: Elevation of S1 above sacral
fusion mass assuming lumbar body shape
Sacralization and lumbarization may be similar in
appearance, requiring evaluation of entire spinal axis to
define anatomy and correct level nomenclature
Image Gallery
Print Images
GRAPHICS
Sagittal cut away graphic through lumbar vertebral bodies
as viewed from the left demonstrates major structures of
the discovertebral unit. The vertebral bodies are joined by
the intervertebral disc and the anterior and posterior
longitudinal ligaments. The posterior elements consist of the
paired pedicles, transverse processes, articular facets, and
lamina and terminates in the dorsally directed spinous
process. The paired ligamentum flavum and interspinous
ligaments join adjacent posterior elements, capped by the
single midline supraspinous ligament.
Lateral view of thoracic vertebral body shows the
characteristic features of this spinal segment. The unique
superior and inferior demifacets form a concavity spanning
the intervening disc to house the rib head and form the
costovertebral joint. The spinous process is typically long
and oblique.
Graphic of cervical vertebral body, viewed from above, is
shown. The lateral margins of the vertebral bodies are
dominated by the facet joints, with their articulating superior
and inferior processes, and the transverse processes with
their characteristic transverse foramen which transmits the
vertebral artery.
Graphic of thoracic vertebral body, viewed from above, is
shown. The thoracic bodies are characterized by long
spinous processes and transverse processes. The complex
rib articulation includes both costotransverse joints and
costovertebral joints.
Graphic of lumbar vertebral body, viewed from above, is
shown. The large sturdy lumbar vertebral bodies connect to
thick pedicles and transversely directed transverse
processes. The facets maintain an oblique orientation
favoring flexion/extension motion.
CERVICAL RADIOGRAPHY
AP view of the cervical spine is shown. The vertebral bodies
show a distinctive shape with their curved lateral margins
with uncinate processes forming the uncovertebral
("Luschka") joints. The pedicles are poorly seen due to their
obliquity to the plane, as are the facet joints. The lateral
masses assume a flowing or undulating contour to the
lateral aspects of the spine. The superior and inferior
endplates are well defined. The bifid spinous processes
project through the vertebra body.
Lateral view of cervical spine is shown. The superior and
inferior vertebral endplates are well defined in this
projection. The pedicles are poorly seen due to obliquity.
The transverse processes overlap the vertebra bodies and
are not well defined. With proper positioning, the facet joints
of each side overlap to merge into what appears to be 1
joint with a well-defined joint space.
THORACIC RADIOGRAPHY
AP view of the thoracic spine is shown. The vertebral
bodies are square with well-defined cortical margins. The
intervertebral disc spaces are small relative to the lumbar
region. The pedicles are visible end on with an oval
configuration. The spinous process are long and obliquely
oriented and extend caudally, overlapping the more inferior
vertebral body on this view.
Lateral view of the thoracic spine is shown. The anterior
and posterior thoracic body cortical margins are well
defined and maintain a smooth alignment in the vertical
direction. The bony endplates are well defined, separating
the thin intervertebral discs. The region of the
costovertebral joints is poorly defined, just anterior to the
inferior margin of the neural foramen. The costotransverse
joints are seen end on.
LUMBAR RADIOGRAPHY
AP view of the lumbar spine is shown. The vertebral bodies
assume a more rectangular appearance in this view with
strong, large ovoid pedicles seen end on. A portion of the
facet joints are visualized, being relatively oriented in the
sagittal plane and allowing flexion and extension. The
posterior elements forming the H pattern are well defined
with their superior and inferior articular processes and
broad lamina. The spinous process is midline, pointing
slightly inferior.
Lateral view of the lumbar spine is shown. The broad and
square-shaped bodies in this view separate the large
intervertebral disc spaces. The anterior and posterior
vertebral body cortical margins line up, allowing a gentle
lordotic curvature. The pedicles and neural foramina are
well visualized in this plane with bony overlap obscuring the
facet joint space.
AXIAL NECT
Axial NECT through midpedicle level of lumbar vertebra
shows the thick pedicles extending into the superior articular
process with the obliquely angled facet (zygapophyseal)
joint. The ligamentum flavum extends to the midline as a
paired structure and laterally along the lamina and facet
joint margins. The basivertebral veins are seen as paired
lucencies in the midline of the posterior portion of the
vertebral body.
Axial CT through the endplate shows the triangular-shaped
junction of the lamina with the dorsally directed spinous
process. The neural foramina are large and directed
laterally.
Axial CT through the intervertebral disc level is shown. The
ligamentum flavum is well defined and does not cross the
midline, extending laterally toward the facet joints.
LUMBAR CORONAL NECT

First of 3 coronal NECT reformats of lumbar spine
presented from anterior to posterior shows the rectangular-
shaped vertebral bodies. The posterior margin of the body
is pierced by the basivertebral veins. The pedicles arise
dorsally from the vertebral bodies and are seen in
transverse section.
Section more posteriorly extending through 3 levels of the
spinal canal is shown. The slightly oblique coronal section
extends from the posterior vertebral body at top, through
the pedicles in the middle, to the lamina at the bottom. The
neural foramina are large and bounded superiorly by the
pedicles.
Section more posteriorly through the articular processes is
shown. The posterior elements in this plane assume a
typical H configuration with the superior and inferior articular
processes forming the vertical components and the lamina
forming the central bar.
CERVICAL 3D-VRT NECT

Anterior view of 3D-VRT NECT examination of the cervical
spine is shown. Cervical vertebral bodies are defined by the
unique paired uncinate processes forming the margin of the
uncovertebral joint (joints of Luschka). The pedicles are
small with large and complex transverse processes with
anterior and posterior tubercles for muscle attachment and
the transverse foramen for the vertebral artery.
Lateral view of a 3D-VRT NECT study of the cervical spine
is shown. The posterior columns or "pillars" of the cervical
spine are well defined in this view comprised of the lateral
masses with their superior and inferior articular processes.
Axial 3D-VRT NECT viewed from below shows the large
transverse foramen for passage of the vertebral arteries.
The spinal canal is large relative to the pedicle and vertebral
body. Note 45° anterior angulation of neural foramina.
THORACIC 3D-VRT NECT

Anterior view of a 3D-VRT NECT examination of thoracic
spine is shown. The intervertebral discs are relatively small
in the thoracic spine relative to cervical and lumbar
segments. The bodies are held rigidly in place by the strong
costotransverse and costovertebral joints for the ribs. The
costovertebral joint crosses the disc with an inferior
demifacet on the superior positioned vertebrae and superior
demifacet on the inferior positioned vertebrae.
Lateral view of a 3D-VRT NECT study of thoracic spine is
shown. The relationship of the neural foramen is well
defined on this view relative to the rib positions.
Axial 3D-VRT examination of the thoracic spine viewed from
below is shown. The rib articulates at 2 points, the
costotransverse joint laterally, and costovertebral joint
medially. The vertebral bodies are heart-shaped, and the
bony spinal canal is small.
LUMBAR 3D-VRT NECT

Anterior view of a 3D-VRT examination of the lumbar spine
is shown. The vertebral bodies are massive with prominent
lateral transverse processes. The intervertebral discs are
large and thick.
Lateral view of a 3D-VRT examination of the lumbar spine is
shown. The large vertebral bodies are offset by the thick
and sturdy posterior elements with their superior and
inferior articular processes, which are angled in a sagittal
plane. Flexion/extension is permitted, but lateral rotation is
limited. The transverse processes jut out laterally for muscle
attachments. The pars interarticularis forms the junction
between the superior and inferior articular processes.
Axial view of a 3D-VRT NECT examination of the lumbar
spine is shown. The spinal canal assumes a more triangular
shape with thick pedicles and the obliquely oriented facets.
CERVICAL SAGITTAL T2 MR
Midline sagittal T2 MR shows the relationship of the cervical
cord, vertebral bodies, and spinous processes with smooth,
straight margins and alignment. The posterior dural margin
merges with the ligamentum flavum and spinous process
cortex low signal. The anterior dural margin merges with the
posterior body cortex and posterior longitudinal ligament.
Paramedian T2 MR shows the lateral edges of the vertebral
bodies and the pedicle, as well as posteriorly the lamina for
the upper segments and the lateral facets at the lower
levels.
Paramedian sagittal T2 MR shows normal alignment of the
lateral cervical bodies and facet joints. The rhomboidal
configuration of the cervical facets is noted with their
complementary superior and inferior articular facets.
THORACIC SAGITTAL T2 MR
First of 3 sagittal midline T2 MR images of the thoracic
spine presented from medial to lateral is shown. The
interspinous and supraspinous ligaments show typical
normal low signal, attaching the adjacent spinous processes
with their well-defined cortical margins and intermediate-
signal fatty marrow. The anterior longitudinal ligament low
signal merges with the low signal of the anterior cortex of
the vertebral body. The posterior longitudinal ligament is not
separately defined from the anterior dural margin.
More lateral T2 MR of the thoracic spine is shown. The
lateral body marrow signal extends into the broad pedicle
with the well-defined superior and inferior articular
processes. The neural foramina are oval with rostral
segmental vessels and nerves.
More lateral T2 MR of thoracic spine shows the
costovertebral joints spanning the posterior intervertebral
discs.
LUMBAR SAGITTAL T2 MR
First of 3 sagittal midline T2 MR images of the lumbar spine
presented from medial to lateral is shown. The medial
portion of the ligamentum flavum is seen as a linear low
signal posterior to the dural margin. The posterior
longitudinal ligament and dura are seen as prominent linear
low-signal line spanning the discs and vertebral bodies. The
anterior longitudinal ligament is seen as a smooth linear low
signal along the anterior cortical margin of the vertebra
body.
More lateral view of the lumbar spine is shown. The
articular processes are seen as oval bone masses posterior
to the high-signal cerebrospinal fluid of the thecal sac. The
ligamentum flavum is more prominent as low signal along
the ventral margin of the posterior elements.
More lateral view of the lumbar spine is shown. The neural
foramina are keyhole-shaped with larger superior portion
bounded superiorly by the inferior margin of the pedicle.
CERVICAL AXIAL T2* MR

First of 3 axial T2* MR images of the cervical spine through
the vertebral body presented from superior to inferior is
shown. The low signal of the anterior and posterior
longitudinal ligament merges with the low signal of the
vertebral body cortical margin and the annulus fibrosus. The
ligamentum flavum is thin in the cervical spine when normal
and does not extend laterally into the neural foramen (unlike
the lumbar spine).
More inferior axial T2* MR of the cervical spine is shown.
The small and obliquely oriented cervical pedicle is well
defined in this plane as well as the lamina. The vertebral
artery lies within the anterolateral transverse foramen.
More inferior axial T2* MR of the cervical spine through the
neural foramen is shown. Anteriorly, the foramen is defined
by the uncinate process and laterally by the superior
articular process.
THORACIC AXIAL T2 MR
First of 3 axial T2 MR images of the thoracic spine through
the intervertebral disc presented from superior to inferior is
shown. The thoracic spine shows coronal orientation of the
facet joints with a less distinct ligamentum flavum. The low-
signal outer component of the annulus fibrosus merges with
the low signal of the anterior longitudinal ligament. The
posterior longitudinal ligament is not visualized.
More inferior view of the thoracic spine through the
vertebral body level is shown. The costovertebral joint is
well defined with the costotransverse joint out of plane of
imaging. The pedicles at this level are short, encompassing
the small central bony canal.
More inferior MR of the thoracic spine is shown. The
costovertebral and costotransverse joints are both
visualized on this section with rectangular-shaped
transverse processes.
LUMBAR SAGITTAL T1 MR
First of 3 T1 sagittal MR images of the lumbar spine
presented from medial to lateral is shown. This midline MR
shows the low signal of the anterior longitudinal ligament
along the anterior vertebral bodies and annulus fibrosus.
The posterior longitudinal ligament is a thin, low-signal band
posterior to the bodies merging with annulus fibrosus at the
disc level.
More lateral view of the lumbar spine is shown. The
articular processes are seen as oval bone masses posterior
to the high-signal cerebrospinal fluid of the thecal sac. The
ligamentum flavum is more prominent as low signal along
the ventral margin of the posterior elements.
More lateral view of the lumbar spine is shown. The neural
foramina are keyhole-shaped with larger superior portion
bounded superiorly by the inferior margin of the pedicle. The
disc level is at the inferior level of the foramen.
LUMBAR AXIAL T1 MR
First of 3 axial T1 MR images of the lumbar spine through
the vertebral body presented from superior to inferior is
shown. The low-signal anterior longitudinal ligament merges
with the low signal of the anterior cortical margin. The
ligamentum flavum is seen along its medial portion,
extending laterally toward the facet joint. The facet joint is
obliquely oriented around 45° with a well-defined joint
space.
More inferior axial T1-weighted MR of the lumbar spine is
shown. The neural foramina are outlined by the high-signal
foraminal fat with the centrally situated ganglion. The lamina
and spinous process form a Y-shaped structure projecting
dorsally.
More inferior axial T1-weighted MR of the lumbar spine
through the intervertebral disc is shown. The facet or
zygapophyseal joints are well visualized with the facet joint
space and ventral margin bounded by the ligamentum
flavum.
Intervertebral Disc and Facet Joints
Main Text
T ERM INOLOGY
Synonyms
• Facet joint; apophyseal joint; zygapophyseal joint
GROSS ANATOMY
Overview
• C2 → S1 vertebrae articulate in 3-joint complex

Secondary cartilaginous joints (symphyses) between
vertebral bodies
Synovial joints between articular processes
(zygapophyses)
• Other articulations
Fibrous (between laminae, transverse/spinous processes)
Uncinate processes (C3-C7)
Intervertebral Discs
• Overview
Lie between thin horizontal hyaline/fibrocartilage
endplates on superior, inferior surfaces of vertebrae
With ALL/PLL, link vertebrae from C2 → sacrum
Comprise 1/3 of spinal column height
– Thickness varies (thinnest in upper T, thickest in
lower L)
– Lumbar discs 7-10 mm thick, 4 cm diameter
Components
– Central nucleus pulposus
– Peripheral annulus fibrosus
Major function is mechanical
– Transmit, distribute load from weight/activity
– Allow flexion/extension, lateral bending, torsion
– Discs loaded preferentially in flexion
• Annulus fibrosus
Concentric series of 15-25 fibrous lamellae
– Surround, constrain nucleus pulposus
– Collagen fibers lie parallel within each lamina
– Fibers oriented 60° to vertical
– Type I collagen predominates in outer annulus
– Type II predominates in inner annulus
Inner annulus blends gradually with nucleus
Outer annulus attaches to ALL, PLL, and to fused
epiphyseal ring of vertebral bodies by Sharpey fibers
Innervation: Branch of ventral primary ramus
Vasculature: Outer annulus supplied by capillaries from
spinal branches of dorsal rami
• Nucleus pulposus
Origin: Remnant of notochord
Eccentric position within annulus
– More dorsal compared to center of vertebral body
Components
– 85-95% water
– Loose fibrous strands of collagen, elastin with
gelatinous matrix
– Scattered chondrocytes
– Major macromolecular component = proteoglycans
– Proteoglycans = protein core + attached
glycosaminoglycan chains
– Glycosaminoglycan chains have negatively charged
sulphate, carboxyl groups
– Cations attract anions → high osmotic pressure
enables disc to absorb water
Except for outer annulus, disc relies on nutrient diffusion
from endplate vessels
– Steep metabolic gradient between vessels, disc
centrum
– Centrum has ↓ glucose + oxygen, ↑ lactic acid
– Carbohydrate utilization dominated by glycolysis
Facet Joints
• Articular processes (zygapophyses)

Paired posterior lateral joints
– Superior facet surface directed dorsally
– Inferior facet surface directed ventrally
– Facets joined by pars interarticularis
True synovial joint
– Hyaline cartilage surfaces, synovial membrane,
fibrous capsule
Orientation
– Obliquely sagittal in lumbar spine (protects disc from
axial rotation)
– Coronal in cervical and thoracic spine (protects
against shear)
Innervation: Nociceptive fibers from medial branch of
dorsal ramus
Function: Load bearing in extension, rotation
• Pars interarticularis
Lies between subatlantal superior/inferior articular facets
C2 unique
– Anterior relation of superior to posterior placed
inferior facet
– C2 pars interarticularis unusually elongated
IMAGING ANATOMY
Overview
• Signal on MR related to water content

Nucleus, inner annulus high signal on T2WI
Outer annulus hypointense on T1 & T2WI
↑ Collagen/proteoglycan cross-linking with age →
decreased water binding, ↓ T2 signal
• Disc bulge
Normal age-related change (begins as early as mid-teens)
Posterior margin convex
Disc extends circumferentially beyond endplates
• Concentric annular tear in posterior disc common
High signal on T2WI
Vascularized granulation tissue enhances on T1 C+

Questions
• Spondylolysis
Pars interarticularis fracture
Superior facets displace ventrally
Inferior facets remain attached to dorsal arch
• Spondylolisthesis
Slip of one vertebrae relative to adjacent level
Many etiologies (congenital dysplasia of articular
processes, trauma, degenerative instability, etc.)
Image Gallery
Print Images
GRAPHICS
Posterior oblique graphic view of the cervical spine is

shown. The facet joint is highlighted with a cutaway view,
showing the opposed cartilaginous articular facets of the
superior and inferior articular processes. The uncovertebral
joint, or joint of Luschka, is along the posterior lateral
margin of the vertebral body and the anterior margin of the
neural foramen.
Sagittal midline graphic through the lumbar disc is shown.
The discovertebral unit is composed of the anterior and
posterior longitudinal ligaments, the annulus fibrosus, the
nucleus pulposus, and the bony and cartilaginous endplates.
The annulus fibrosus is composed of multiple layers, similar
to an onion skin in appearance. The inner annulus merges
into the central, more gelatinous nucleus pulposus. The
endplate maintains nutrition to the disc via diffusion of
solutes.
3D-VRT NECT
Lateral oblique view of a 3D-VRT NECT examination of the
cervical spine is shown. The facet joints in the cervical spine
form paired vertical columns or "pillars", which together with
the discovertebral unit provide the 3-pronged structural
support for the cervical segment. The obliquity of the facet
joints allow degrees of both flexion/extension and rotation.
Posterior view of a 3D-VRT NECT examination of the
thoracic spine is shown. The coronally oriented facet joints
are viewed from their posterior margins with the interlocking
superior and inferior processes. Structural stability is
provided by the tough costovertebral and costotransverse
joints and their accompanying ligaments.
Oblique view of a 3D-VRT NECT examination of the lumbar
spine shows the Scotty dog appearance of the transverse
process, articular processes, and pars interarticularis.
CERVICAL AXIAL & SAGITTAL NECT

Axial NECT of the cervical spine is shown. The facet joint is
viewed obliquely, with the superior to inferior articular
process forming the oval-shaped facet mass. The
intervertebral disc is cup-shaped, bounded along the
posterior aspect by the upturned bony uncinate process.
The anterior border of the neural foramen is shielded from
the intervertebral disc by the uncinate process.
More inferior axial NECT view of the cervical spine is
shown. The cup shape of the intervertebral disc is also
apparent on this section with upturned bone of the posterior
and lateral endplates. The facet joint is again viewed in an
oblique section, forming an oval facet mass.
Sagittal NECT reformat of the cervical spine better defines
the margins of the facet joints with their oblique inferior
course. Just ventral to the facets is the long course of the
vertebral artery.
THORACIC AXIAL & SAGITTAL NECT

Axial NECT through the thoracic spine is shown. The facet
joints show a more coronal orientation, relative to the
oblique coronal (or horizontal) cervical joint orientation, and
the oblique sagittal orientation of the lumbar joints. The bony
spinal canal containing the thoracic cord is relatively small
with respect to the body and posterior elements.
More inferior axial NECT view of the thoracic spine is
shown. The coronal-oriented facet joints are again
visualized, merging into the lamina and inferiorly directed
spinous process. The costovertebral joint laterally provides
additional stabilization.
Sagittal reformat of a thoracic spine NECT is shown. The
facet joint orientation is well defined in this view, showing
the articulation of the adjacent vertebral bodies with their
superior and inferior articular processes.
LUMBAR AXIAL & SAGITTAL NECT

Axial NECT of the lumbar spine is shown. The oblique
sagittal orientation of the facet joint is evident in this section
with the well-defined articular processes forming the
posterolateral margin of the spinal canal. The ventral margin
of the facet forms the posterior aspect of the neural
foramen.
More inferior axial NECT section of the lumbar spine
through the pedicles is shown. The oblique sagittal
orientation of the facets is maintained.
Sagittal reformat of NECT examination of the lumbar spine
is shown. The facet joints are well defined with their large,
robust superior and inferior articular processes. The ventral
facet joint forms the posterior margin of the neural foramen.
The anterior margin of the neural foramen is composed of
cortical margin of 2 vertebral bodies and the intervening
intervertebral disc.
SAGITTAL T2 INTERVERTEBRAL DISC

Sagittal midline T2 MR through the cervical spine is shown.
The intervertebral discs are relatively small with thin, low-
signal outer annular fibers and a predominate high-signal
central nucleus pulposus. The intranuclear cleft is not usually
visible.
Sagittal T2 MR of the thoracic spine is shown. The vertebral
bodies are square in morphology with slightly more
pronounced intervertebral discs. The intranuclear cleft is not
usually visible in the mid and upper thoracic region, but
becomes progressively more pronounced at the
thoracolumbar junction.
Sagittal T2 MR of the lumbar spine is shown. The
intervertebral discs are large with pronounced low-signal
annulus fibrosus. The intranuclear cleft is a typical feature of
the adult lumbar disc on T2 MR images.
SAGITTAL T2 FACET JOINTS

Sagittal T2 MR through the cervical spine is shown. The
cervical pillars are readily visible, composed of the adjacent
superior and inferior articular processes and the intervening
joint. The C2 body is transitional with the inferior articular
process forming the rostral part of the pillar. The superior
process of C2 is more ventral, and articulates with the
inferior articular facet of C1.
Sagittal T2 MR of the thoracic spine is shown. The
orientation of the thoracic facets allows good visualization of
the facet joints as well as the neural foramen.
Sagittal T2 MR of the lumbar spine is shown. The facet
joints are more obliquely oriented, allowing flexion and
extension. The superior articular process forms the dorsal
margin of the neural foramen and is anterior to the inferior
articular process.
Paraspinal Muscles
Main Text
T ERM INOLOGY
Abbreviations
• Origin (O), insertion (I), innervation (N), function (F)

• Ligamentum nuchae (LN), spinous process (SP), transverse
process (TP)
GROSS ANATOMY
Overview
• Musculature of back arranged in layers

Superficial (extrinsic or "immigrant") muscles
– Innervated by anterior rami of spinal nerves
– Run between upper limb, axial skeleton
Deep (intrinsic or "true") muscles
– Innervated by spinal nerve dorsal rami, deep to
thoracolumbar fascia
IMAGING ANATOMY
Superficial Muscles
• Trapezius
O: External occipital protuberance, LN, SP C7-T12
I: Clavicle, acromion, scapular spine
F: Rotation, adduction, raising, lowering scapula
N: CNXI, C3, C4
• Latissimus dorsi
O: Lumbar aponeurosis to T6-12 SP, iliac crest, lower 4
ribs
I: Intertubercular groove of humerus
F: Extends, adducts, rotates arm medially
N: Thoracodorsal
• Levator scapulae
O: Posterior tubercles + TP C1-4
I: Medial border scapula
F: Elevate and rotate scapula
N: C3-5
• Rhomboid minor
O: LN, SP C7-T1
I: Medial border scapula
F: Scapula medially
N: Dorsal scapular
• Rhomboid major
O: SP T2-5
I: Medial border scapula, below spine
F: Scapula medially
N: Dorsal scapular
Deep Muscles
• Cervical/thoracic/lumbar general musculature

F: All extend vertebral column
N: All by posterior divisions of spinal nerves
Splenius capitis
– O: LN, SP C7-T3
– I: Occipital bone, mastoid
– F: Draws head back, bends head laterally
Splenius cervicis
– O: SP T3-6
– I: TP C1-3
Erector spinae (iliocostalis, longissimus, spinalis)
– O: SP T1-L5, lower 6 ribs, iliac crest, TP T1-5
– I: Upper border ribs 1-6, TP C2-7, lumbar and
thoracic TP
Semispinalis (capitis, cervical, thoracic)
– O: TP C7-T10
– I: SP C2-T4, occipital bone
– F: Rotate head/column to opposite side
Multifidus
– O: C4-7 articular processes, thoracic TP, lumbar
superior articular facets
– I: Crosses 1-4 vertebrae to reach SP C2-L5
– F: Rotate column to opposite side
Rotatores
– O: TP
– I: SP adjacent vertebrae
– F: Rotate column to opposite side
Interspinalis
– Connect apices of adjoining SP C2-L5
Intertransverse
– Connect adjacent TP
• Suboccipital
Rectus capitis
– O: SP C2, posterior arch C1
– I: Occipital bone
– F: Extend, rotate head
Oblique capitis superior
– O: TP C1
– F: Extend, bend head same side
Oblique capitis inferior
– O: Spine of C2
– I: TP C1
– F: Turn head same side
• Prevertebral
Rectus capitis
– O: TP C1
– F: Flexes head
– N: C1-2
Longus colli
– O: TP C3-5, vertebral bodies C5-T3
– I: Anterior arch C1, vertebral bodies C2-4
– F: Flexes, rotates neck
– N: C2-7
Longus capitis
– O: TP C3-6
– F: Flexes head
– N: C1-3
Scalene (anterior, middle, posterior)
– O: TP, vertebrae C2-7
– I: Ribs 1, 2
– F: Lateral bending, flexing neck
– N: C5-8
Psoas (major, minor) functionally part of iliac region,
thigh flexors
Image Gallery
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GRAPHICS
Axial graphic of the cervical muscles is shown. The
superficial neck muscles are dominated by the anterior
sternocleidomastoid muscles and the posterior trapezius
muscles. The anterolateral deep neck shows the scalene
muscles with the brachial plexus passing between the
anterior and middle scalene muscles. The dorsal neck
muscles are a complex of semispinalis, longus capitis, and
splenius capitis muscles.
Axial graphic of the lumbar muscles is shown. The dorsal
muscle complex contains the longissimus and multifidus
muscles. The quadratus lumborum muscle defines the
planes between middle and anterior layers of the
thoracolumbar fascia. The large psoas muscles define the
lateral paravertebral regions.
AXIAL CECT: CERVICAL

First of 3 axial CECT images of the cervical spine presented
from superior to inferior is shown. The ligamentum nuchae
and many of the deep neck extensor muscles are attached
to the spinous processes within the cervical spine, such as
the semispinalis (thoracic and cervical components),
multifidus, and interspinalis muscles. The vertical segment
of the longus colli is located within the shallow depression
along the anterior margins of the vertebral bodies.
Image through the midcervical spine is shown. The paired
deep cervical musculature is identified in this view, including
the multifidus, semispinalis, and splenius capitis muscles.
The longus colli attaches to the anterior tubercle, while the
longus capitis is slightly more lateral.
View of the lower cervical spine is shown. The anterior and
middle scalene muscles insert on the 1st rib with the
posterior scalene inserting on the 2nd rib.
AXIAL CECT: THORACIC

First of 3 axial CECT images of the thoracic spine
presented from superior to inferior is shown. The posterior
margins of the transverse processes provide attachment for
the deep thoracic muscles. The erector spinae muscle
group includes the medial spinalis thoracis, longissimus, and
laterally positioned iliocostalis muscles. The spinous
processes provide attachment for multiple muscle groups,
such as the more superficial trapezius, rhomboids,
latissimus dorsi, serratus posterior, as well as the deep
muscles group.
View of the midthoracic spine is shown. Many small muscle
groups are attached to the posterior elements. The
transversospinalis group includes the interspinalis,
rotatores, multifidus, and semispinalis muscles.
Image at the thoracolumbar junction is shown. The erector
spinae group (e.g., medial multifidus and the lateral
iliocostalis muscles) are well defined here.
AXIAL CECT: LUMBAR

First of 3 axial CECT images through the lumbar spine
presented from superior to inferior is shown. The posterior
layer of thoracolumbar fascia is adjacent to the erector
spinae muscle group. The quadratus lumborum muscle
provides the landmark for the middle and anterior layers;
the anterior margin of the muscle is the anterior fascial
layer, while the posterior margin of the muscle defines the
middle layer.
Image through the midlumbar spine is shown. The psoas
muscles are prominent on either side of the vertebral body.
The psoas muscles attach to the superior and inferior
margins of all the lumbar vertebral bodies. The posterior
layer of the thoracolumbar fascia is the boundary of the
dorsal spinal muscles.
Image through the S1 level is shown. This level is defined by
the ventral psoas and iliacus muscles, the dorsolateral
gluteus maximus, and the dorsomedial erector spinae
group.
CORONAL CECT: THORACOLUMBAR

First of 3 coronal CECT images of the thoracolumbar
junction dorsal musculature presented from posterior to
anterior is shown. The longissimus thoracis bends the spinal
column to one side and can depress the ribs. The
semispinalis thoracis rotates the spinal column to one side,
while the multifidus muscles and the small rotatores muscles
rotate the column to the opposite side.
Image of the thoracolumbar junction dorsal musculature, just
ventral to superior image is shown. The multiple paired
small slips of erector muscles are demonstrated with the
rotatores and spinalis thoracis shown.
Image of the thoracolumbar junction dorsal musculature, just
ventral to upper image is shown. The oblique angled
multifidus muscles are shown, extending from transverse
processes toward the spinous processes.
Craniocervical Junction
Main Text
T ERM INOLOGY
Definitions
• Craniocervical junction (CCJ): C1, C2, and articulation with

skull base
GROSS ANATOMY
Overview
• CCJ comprises occiput, atlas, axis, their articulations,

ligaments
Components
• Bones
Occipital bone
– Occipital condyles are paired, oval-shaped, inferior
prominences of lateral exoccipital portion of
occipital bone
– Articular facet projects laterally
C1 ( a tlas)
– Composed of anterior and posterior arches; no body
– Paired lateral masses with their superior and inferior
articular facets
– Large transverse processes with transverse foramen
C2 ( a xis)
– Large body and superiorly projecting odontoid
process
– Superior articulating facet surface is convex and
directed laterally
– Inferior articular process + facet surface typical of
lower cervical vertebrae
– Superior facet positioned relatively anteriorly;
inferior facet posterior with elongated pars
interarticularis
• Joints
Atlantooccipital joints
– Inferior articular facet of occipital condyle: Oval,
convex surface; projects laterally
– Superior articular facet of C1: Oval, concave
anteroposteriorly; projects medially
Median atlantoaxial joints
– Pivot-type joint between dens + ring formed by
anterior arch + transverse ligament of C1
– Synovial cavities between transverse
ligament/odontoid and atlas/odontoid articulations
Lateral atlantoaxial joints
– Inferior articular facet of C1: Concave mediolaterally;
projects medially in coronal plane
– Superior articular facet of C2: Convex surface;
projects laterally
• Ligaments (from anterior to posterior)
Anterior atlantooccipital membrane : Connects anterior
arch C1 with anterior margin of foramen magnum
Odontoid ligaments
– Apical ligament: Small fibrous band extending from
dens tip to basion
– Alar ligaments: Thick, horizontally directed
ligaments extending from lateral surface of dens tip
to anteromedial occipital condyles
Cruciate ligament
– Transverse ligament: Strong horizontal component
between lateral masses of C1, passes behind dens
– Craniocaudal component: Fibrous band running
from transverse ligament superiorly to foramen
magnum and inferiorly to C2
Tectorial membrane : Continuation of posterior
longitudinal ligament; attaches to anterior rim of
foramen magnum (posterior clivus)
Posterior atlantooccipital membrane
– Posterior arch C1 to margin of foramen magnum
– Deficit laterally where vertebral artery enters on
superior surface of C1
• Biomechanics
Atlantooccipital joint: 50% cervical flexion/extension and
limited lateral motion
Atlantoaxial joint: 50% cervical rotation
IMAGING ANATOMY
Overview
• Lateral assessment of CCJ

C1-2 interspinous space
– ≤ 10 mm
Atlantodental interval (ADI)
– Adults < 3 mm, children < 5 mm in flexion
Pseudosubluxation
– Physiologic anterior displacement seen in 40% at C2-
3 level and 14% at C3-4 level to age 8
– Anterior displacement of C2 on C3 up to 4 mm
Posterior cervical line : Line drawn from anterior aspect
of C1-3 spinous processes → anterior C2 spinous
process should be within 2 mm of this line
Wackenheim line
– Posterior surface of clivus → posterior odontoid tip
should lie immediately inferior
– Relationship does not change in flexion/extension
Welcher basal angle
– Angle between lines drawn along plane of sphenoid
bone and posterior clivus
– Normal: < 140°; average: 132°
Chamberlain line
– Between hard palate and opisthion
– Odontoid tip ≥ 5 mm above line abnormal
McGregor line
– Between hard palate to base of occipital bone
– Odontoid tip ≥ 7 mm above line abnormal
Clivus canal angle
– Junction of Wackenheim line and posterior vertebral
body line
– 180° extension, 150° flexion, < 150° abnormal
McRae line
– Drawn between basion and opisthion
– Normal 35 mm diameter
• Frontal assessment of CCJ
Lateral masses of C1 and C2 should align
– Overlapping lateral masses can be normal variant in
children
Atlantooccipital joint angle
– Angle formed at junction of lines traversing joints
– 125-130° normal, < 124° may reflect condyle
hypoplasia
Image Gallery
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GRAPHICS
Sagittal midline graphic of the craniocervical junction (CCJ)

is shown. The complex articulations and ligamentous
attachments are highlighted. The midline atlantoaxial
articulations consist of anterior and posterior median
atlantoaxial joints. The anterior joint is between the posterior
aspect of the anterior C1 arch and the ventral aspect of the
odontoid process. The posterior joint is between the dorsal
aspect of the odontoid process and the cruciate ligament.
The midline view shows a series of ligamentous connections
to the skull base, including the anterior atlantooccipital
membrane, apical ligament, superior component of cruciate
ligament, tectorial membrane, and posterior atlantooccipital
membrane.
Posterior view shows the CCJ with posterior elements cut

away to define the components of the cruciate ligament and
alar ligaments.
C1 GRAPHICS
Axial graphic shows atlas viewed from above. The
characteristic ring shape is shown and composed of
anterior and posterior arches and paired large lateral
masses. The superior articular facet is concave
anteroposteriorly and projects medially for articulation with
the convex surface of the occipital condyle at the
atlantooccipital joint. The anterior arch articulates with the
odontoid process at the anterior median atlantoaxial joint.
Axial graphic shows the atlas viewed from below. The large
inferior facet surface is concave mediolaterally and projects
medially for articulation with the convex surface of the
superior articular facet of C2. The canal of the atlas is ~ 3
cm in AP diameter. Spinal cord, odontoid process, and free
space for cord are each ~ 1 cm in diameter. The size of the
anterior midline tubercle of the anterior arch and the spinous
process of the posterior arch are quite variable.
C2 GRAPHICS
Axis viewed from the anterior perspective is shown. The
odontoid process is the "purloined" embryologic centrum of
C1, which is incorporated into C2, giving C2 its unique
morphology. The C2 body laterally is defined by large
lateral masses for articulation with the inferior facet of C1.
The elongated pars interarticularis of C2 ends with the
inferior articular process for articulation with the superior
articular facet of C3.
Axis viewed from the posterior perspective is shown. The
odontoid process has anterior and posterior joints for
articulation with C1. The anterior median joint articulates
with the C1 arch, while the posterior median joint (shown
here) involves the transverse ligament.
CRANIOMETRY GRAPHICS
Sagittal graphic shows important skull base craniometry.
The Chamberlain line (orange) is drawn between the hard
palate and the opisthion. The McGregor line (yellow) is
drawn from the hard palate to the caudal point (base) of the
occipital bone. The Wackenheim line (green) is drawn along
the posterior surface of the clivus. The McRae foramen
magnum line (blue) is drawn between the basion and the
opisthion. The Redlund-Johnell line (red) is drawn from the
base of C2 to the McGregor line.
Sagittal midline graphic shows the Welcher basal angle,
which is the angle between the lines drawn along the plane
of the sphenoid bone and along the clivus (nasion to sella,
sella along posterior clivus to basion). Normal is < 140°;
platybasia if > 140°.
Coronal graphic of the CCJ shows lines drawn along the
atlantooccipital joints to measure the atlantooccipital joint
angle. Normal is 125-130°; < 124° may reflect condyle
hypoplasia.
BONE CT AND T1 MR CRANIOMETRY

Sagittal CT reformat in the midline is shown. The
Chamberlain line is shown in orange extending from the hard
palate to the opisthion. Projection of up to 1/3 of the dens
(5 mm) above this line is normal. The Wackenheim line is
shown in green along the clivus. The dens should lie
immediately inferior to this line, and any intersection is
considered abnormal.
Sagittal T1 MR shows the Chamberlain line in orange. The
odontoid tip ≥ 5 mm above the line defines the basilar
impression. The McGregor line is shown in yellow. This line
has the same significance as the Chamberlain line with the
odontoid tip ≥ 7 mm above the line, defining the basilar
impression.
LATERAL RADIOGRAPHY CRANIOMETRY

In this lateral plain film radiograph, the Welcher basal angle
is shown in red. The platybasia exists if the angle is > 140°
(normal is < 140°). The Ranawat measurement is shown in
blue and is used to assess collapse at the C1-2 articulation.
Measurement is taken from the center of C2 pedicle to the
line connecting the anterior and posterior arches of C1.
Normal is ~ 14 mm in men and ~ 13 mm in women (< 13
mm is consistent with impaction).
In this lateral plain film radiograph, the McRae line is shown
in blue. Normal is ~ 35 mm in diameter. The normal
odontoid process does not extend above this line. The
Redlund-Johnell measurement is shown in red. This
measurement is from the base of the C2 body to the
McGregor line (shown in yellow). Normal is ~ 34 mm in men
and ~ 28 mm in women.
LATERAL RADIOGRAPHY
Lateral plain film radiograph of the cervical spine in a child
shows physiologic anterior displacement of C2 with respect
to C3 and C3 with respect to C4, the so-called
pseudosubluxation. Physiologic subluxation is differentiated
from pathologic anterior displacement by the absence of
prevertebral soft tissue swelling, reduction on extension,
and assessment of the posterior cervical line.
Posterior cervical line is drawn along the anterior aspect of
the C1-3 spinous processes. The anterior C2 spinous
process should be within 2 mm of this line in flexion and
extension. The atlantodental interval is < 3.5 mm in children
and < 3 mm in adults.
RADIOGRAPHY
AP open-mouth view shows the odontoid process. With
proper positioning, the odontoid process is visualized in the
midline with symmetrically placed lateral C1 masses on
either side. The medial space between the odontoid and C1
lateral masses should be symmetric as well. The lateral
cortical margins of the C1 and C2 lateral masses should
align. The atlantoaxial joints are visible bilaterally with
smooth cortical margins. The bifid C2 process should not be
confused for fracture.
Lateral radiograph shows the CCJ. There is smooth
anatomic alignment of the posterior vertebral body margins
and the posterior spinolaminar line of the posterior
elements. The anterior arch of C1 should assume a well-
defined oval appearance with sharp margination between
the anterior arch of C1 and the odontoid process.
CORONAL BONE CT
First of 2 coronal bone CT reconstructions of the CCJ
presented from anterior to posterior is shown. The odontoid
process is visualized in the midline as a sharply corticated,
bony peg with symmetrically placed lateral C1 masses on
either side. The lateral cortical margins of the C1 lateral
masses and the C2 lateral masses should align. The
atlantooccipital and atlantoaxial joints are visible bilaterally
with even joint margins and sharp cortical margins.
More posterior view of the CCJ is shown. Both
atlantooccipital joints are now well defined with smooth
cortical margins sloping superolateral to inferomedial. The
atlantoaxial joints are smoothly sloping inferolateral to
superomedial.
AXIAL BONE CT
First of 6 axial bone CT images through the CCJ presented
from superior to inferior is shown. The anterolateral margin
of the foramen magnum is formed by the prominent occipital
condyles, which articulate with the superior articular facets
of the C1 lateral masses.
More inferior image of the CCJ is shown. The anterior arch
of C1 is now well defined with the odontoid process of C2
coming into plane. The atlantooccipital joint is seen in
oblique section and therefore has poorly defined margins.
The odontoid is tightly applied to the posterior margin of the
C1 arch, held in place by the strong transverse component
of the cruciate ligament.
Image at the level of the atlas is shown. The unique
morphology of the C1 body is defined with its large
transverse process with transverse foramen and ring shape.
CT through the lateral atlantoaxial joints is shown. This
section defines the junction of the odontoid process with the
body of C2. The obliquely oriented atlantoaxial joints are
partially seen with the C1 component lateral to the joint
space and the C2 component medial.
Image through the inferior C2 body level shows a large C2
vertebral body and vertebral arch formed by gracile
pedicles and laminae.
Image through C2-3 intervertebral disc level is shown. The
C2-3 neural foramen is well defined with the posterior
margin formed by the superior articular process of C3. The
spinous process of C2 is large and typically bifid. The C2-3
disc assumes the characteristic cervical cup-shaped
morphology bounded by uncinate processes.
3D-VRT NECT
Anterior view shows a 3D-VRT NECT examination. The
unique ability of the C1-2 articulation to provide rotation is
apparent in this projection with the bony peg of the odontoid
process forming the pivot point for the C1 ring.
Lateral view shows a 3D-VRT NECT examination. The
complex lateral components of C1 and C2 bodies are
highlighted in this projection. The superior facet of C2 is
anteriorly positioned to articulate with the inferior articular
facet of C1, while the inferior articular facet of C2 is more
posterior, forming the top of the cervical articular "pillar."
The articular facets are separated by the elongated pars
interarticularis.
Superior view shows a 3D-VRT NECT examination depicting
the relationship of the C1 ring with underlying C2 odontoid
and lateral masses.
SAGITTAL T1 MR
First of 3 parasagittal T1 MR images from medial to lateral
through the atlantooccipital joint is shown. This image
extends through the lateral cortical margin of the odontoid,
which is incompletely visualized. The anterior arch of C1 is
obliquely visualized as it curves posterolaterally. The lateral
extension of the cruciate ligament, the transverse ligament,
is prominent.
The relationship of the occipital condyle, C1 lateral mass,
and atlantoaxial joint is highlighted in this image. The
articular surface of the occipital condyle is convex and the
superior facet of C1 is concave, allowing for
flexion/extension.
More lateral image of the CCJ is shown. The
atlantooccipital joint and atlantoaxial joints are visible with
sharp, smooth cortical margins.
SAGITTAL T2 MR
Series of sagittal T2 MR images progressing from midline
laterally is shown. Sagittal midline image shows the
relationship of the anterior arch of C1, odontoid process,
and the cruciate ligament to the anterior and posterior
margins of the foramen magnum.
Parasagittal image shows the relationship of the anterior
arch of C1 to the alar and transverse ligaments extending
laterally to attach to the occiput and C1, respectively.
Sagittal image through the occipital condyle, atlantooccipital
joint, and the lateral mass of C1 is shown. Two segments of
the vertebral artery are identified, exiting the C2 transverse
foramen and the horizontal component passing over the
posterior arch of C1.
SAGITTAL CT AND MR
Sagittal midline CT reformat shows the ligamentous
structures visible at the CCJ. The apical ligament is visible
as a linear band between the odontoid tip and clivus. The
tectorial membrane is the superior extension of the
posterior longitudinal ligament. The anterior atlantooccipital
membrane is the extension of the anterior longitudinal
ligament.
Sagittal T1 MR midline image of the CCJ is shown. The
atlantodental interval is well defined by the adjacent low-
signal cortical margins of the C1 anterior arch and the
odontoid process. The cruciate ligament is a low-signal
band dorsal to the odontoid.
Sagittal T2 MR of the CCJ is shown. The tectorial
membrane, superior extension of cruciate ligament, apical
ligament, and anterior atlantooccipital membranes are
evident.
CORONAL T2 MR
First of 3 images progressing from superior to inferior of the
CCJ is shown. Anterior image shows the skull base (clivus)
and the relationship to the lateral masses of C1, the
atlantoaxial joint, and the odontoid process.
More posterior image shows the relationship of the
posterior aspect of the odontoid process to the cruciate
ligament and its lateral extension (transverse ligament). The
vertical load-bearing components of the occipital condyles
and lateral masses of C1 and C2 are well defined.
More posterior image shows the midportion of the
transverse ligament immediately posterior to the odontoid
process as well as the more superiorly directed alar
ligaments connecting to the occipital bone.
AXIAL T2 MR
First of 3 axial T2 MR images through the CCJ from
superior to inferior shows the anterior margin of the
foramen magnum, the upper cervical cord, and the vertebral
arteries making the transition to the intradural position
(V3/V4).
Image at the level of the transverse ligament and lateral
masses of C1 is shown. The transverse ligament is well
defined as a band of low signal posterior to the odontoid
process.
More inferior image shows the odontoid base joining the
body of C1, as well as the C1-C2 joints laterally.
Cervical Spine
Main Text
T ERM INOLOGY
Definitions
• Cervical spine consists of 7 uppermost spinal bones,

including atlas (C1) and axis (C2); subaxial cervical spine =
C3-C7
GROSS ANATOMY
Overview
• Consists of 7 vertebrae (C1-C7)

Craniocervical junction (CCJ) : C1, C2, and articulation
with skull base constitutes CCJ
Subaxial spine : C3-C7
– C3-C6 typical cervical vertebrae
– C7 has features that differ slightly from C3-C6
Components of Subaxial Cervical Spine
• Bones C3-C7
Body
– Small, broader transversely than in AP dimension
– Posterolateral edges of superior surface are turned
upward = uncinate processes
Vertebral arch
– Pedicle: Delicate, projects posterolaterally
– Lamina: Thin and narrow
– Vertebral foramen: Large, triangular-shaped
Transverse process
– Project laterally and contain foramen for vertebral
artery
– Anterior and posterior tubercles are separated by
superolateral groove (lateral neural recess) for
exiting spinal nerve
Articular processes
– Superior and inferior articular processes with
articular facets oriented ~ 45° superiorly from
transverse plane
– Form paired osseous shafts posterolateral to
vertebral bodies = articular pillars
Spinous process: Short and bifid
C7 unique features
– Spinous process: Long, prominent
– Transverse process: Short and project inferolaterally
compared with T1 spinous processes, which are
long and project superolaterally
• Intervertebral foramen
Oriented anterolaterally below pedicles at ~ 45° to
sagittal plane
• Joints
Intervertebral disc
– Narrowest in cervical region
– Thinner posteriorly than anteriorly
– Do not extend to lateral margins of vertebral bodies
in cervical spine → joints of Luschka
Uncovertebral joint (joints of Luschka)
– Oblique, cleft-like cavities between superior surfaces
of uncinate processes and lateral lips of inferior
articular surface of next superior vertebrae
– Lined by cartilaginous endplate of vertebral body
– No true synovial lining present; contains serum,
simulating synovial fluid
– Uncinate process develops during childhood with
uncovertebral joint forming by fibrillation and
fissuring in fibers of annulus fibrosus
Facet (zygapophyseal) joints
– Facet joints oriented ~ 45° superiorly from transverse
plane in upper cervical spine; assume more vertical
orientation toward C7
– Formed by articulation between superior and inferior
articular processes = articular pillars
– Forms 2 sides of flexible tripod of bone (vertebral
bodies, right and left articular pillars) for support of
cranium
• Ligaments
Anterior and posterior longitudinal, ligamentum flavum,
interspinous and supraspinous ligaments
Additional ligaments of CCJ include apical, alar, and
cruciate ligaments
• Biomechanics
Subaxial cervical spine shows free motion range relative
to remainder of presacral spine
– Cervical extension checked by anterior longitudinal
ligament and musculature
– Cervical flexion checked by articular pillars and
intertransverse ligaments
IMAGING ANATOMY
Lateral Assessment of Subaxial Spine
• Principles apply equally to radiography, CT, or MR

• Prevertebral soft tissues : Distance between air column and
anterior aspect of vertebral body
Adults: < 7 mm at C2 and < 22 mm at C6
Child: < 14 mm at C6
• Bony alignment
Anterior vertebral line : Smooth curve paralleling
anterior vertebral cortex
– Less important than posterior cortical line
Posterior vertebral line : Smooth curve paralleling
posterior vertebral cortex
– Translation > 3.5 mm is abnormal
– Flexion and extension allow physiological offset < 3
mm of posterior cortical margin of successive
vertebral bodies
Spinolaminar line : Smooth curve from opisthion to C7
formed by junction of laminae with spinous processes
Spinous process angulation : Cervical spinous processes
should converge toward common point posteriorly
– Widening is present when distance is > 1.5x
interspinous distance of adjacent spinal segments
Frontal Assessment of Subaxial Spine
• Lateral masses: Bilateral smooth undulating margins

• Spinous processes: Midline
Lateral rotation of 1 spinous process with respect to
others is abnormal
• Interspinous distance: Symmetric throughout
Interspinous distance 1.5x distance of level above or
below is abnormal
Image Gallery
Print Images
GRAPHICS
Graphic of a typical cervical vertebra viewed from above

demonstrates important morphology. The vertebral body is
broader transversely than in the AP dimension, the central
vertebral canal is large and triangular in shape, pedicles are
directed posterolaterally, and the laminae are delicate and
give rise to a spinous process with a bifid tip. Lateral
masses contain the vertebral foramen for passage of the
vertebral artery and veins.
Frontal graphic of subaxial cervical spine with cutout shows
the intervertebral disc and uncovertebral joints. Paired
lateral articular "pillars" are formed by articulation between
superior and inferior articular processes.
Lateral graphic of 2 consecutive typical cervical vertebrae
with cutout shows facet (zygapophyseal) joint detail. Note
also the prominent groove on the superior surface of the
transverse process for exiting spinal nerves.
Sagittal midline graphic of the cervical spine and cord
shows a gentle lordotic curve and smooth alignment of the
adjacent vertebrae. C1, C2, and their articulation with the
skull base constitutes the craniocervical junction. C3-C7
constitutes the subaxial cervical spine. C3-C6 are regarded
as typical cervical vertebrae, whereas C7 has features that
differ slightly from C3-C6, including a long, prominent
spinous process.
Sagittal graphic through the cervical neural foramen shows
the position of exiting spinal nerves within the lower part of
the neural foramen. Neural foramina are oriented
anterolaterally (compared with thoracic and lumbar
regions). The anterior boundary of the neural foramen
include the uncinate process, intervertebral disc, and
vertebral body from inferior to superior. Pedicles form
superior and inferior boundaries. The posterior boundary is
the facet joint complex.
GRAPHIC AND 3D-VRT NECT

Coronal graphic of the cervical spine shows vertebrae and
corresponding cervical nerves. The vertebra are numbered
and are shown with their exiting nerves. There are 8 cervical
nerves with C1 nerve exiting above the C1 body and C2
nerve exiting at the C1-C2 level. The C8 nerve exits at C7-
T1. Below this level, the thoracic roots exit below their
respective numbered vertebra. The roots exit inferiorly
within the neural foramen, along the bony groove in the
transverse process.
Coronal 3D-VRT examination of the cervical spine is viewed
posteriorly with the dorsal elements partially removed to
show the dorsal vertebral body surface. The concept of the
cervical articular "pillars" is well shown in this view with the
facets forming paired columns of bone with superior and
inferior articulating facets.
GRAPHIC AND LATERAL RADIOGRAPH

Sagittal midline graphic of the cervical spine is shown. The
normal cervical spine shows a smooth lordotic curve with
smooth alignment of a series of lines going from ventral to
dorsal, including prevertebral soft tissues (orange), anterior
vertebral body cortical margins (yellow), posterior vertebral
body margins (green), and posterior spinolaminar line
(blue). In adults, the prevertebral soft tissues measure < 7
mm at C2 and < 22 mm at C6. In children, they measure <
14 mm at C6.
Lateral radiograph of the cervical spine shows normal
alignment. A series of gently curving lines make up the
normal cervical curvature, extending from prevertebral soft
tissues to the posterior spinolaminar line. In addition, the
cervical spinous processes should all converge toward a
common point posteriorly.
RADIOGRAPHY
AP plain film view of the cervical spine is shown. The
articular facets are viewed obliquely in this projection and
therefore not defined, giving the appearance of smoothly
undulating lateral columns of bone. The superior and inferior
vertebral endplate margins are sharp with regular spacing
of the intervertebral discs. The spinous processes are
midline. C7 transverse process is directed inferolaterally
compared with T1, which is directed superolaterally.
Lateral radiograph of cervical spine is shown. The
prevertebral soft tissues should form a defined, abrupt
"shelf" at ~ C4/C5 where the hypopharynx/esophagus
begins, hence thickening the prevertebral soft tissues. The
bony cervical spine is aligned from anteriorly to posteriorly
with the anterior vertebral body margins, the posterior
vertebral body margins, and ventral margins of the spinous
processes (spinolaminar line).
RADIOGRAPHY AND 3D-VRT NECT

Oblique radiograph of the cervical spine best demonstrates
the neural foramina as these are oriented obliquely at ~ 45°
from the sagittal plane. With the patient rotated to the left,
the radiograph demonstrates the right-sided foramina. The
anterior boundary of the neural foramina includes the
uncinate process, intervertebral disc, and vertebral body.
The posterior boundary is the facet joint complex. The
articular pillar facet joints are viewed obliquely and hence
are not well defined. The lamina are seen end on and hence
sharply corticated.
Oblique 3D-VRT examination of the cervical spine shows
the neural foramina end on. The groove on the superior
surface of the transverse processes for the exiting spinal
nerves is well shown.
3D-VRT NECT
Anterior view of 3D-VRT NECT examination of the cervical
spine is shown. The wide neural foramina with the groove or
sulcus on the superior surface of the transverse processes
for the exiting nerves are well seen. The transverse
processes with the tubercles for muscle attachments are
well identified from C3-C7 levels. The uncinate processes
are superior bony projections along the posterolateral
margins of the vertebral bodies and form the uncovertebral
joints with the adjacent superior vertebral body.
Lateral view of 3D-VRT NECT examination of the cervical
spine is shown. The facet joints are seen in profile angled ~
45° superiorly from the transverse plane. They align in a
smooth interlocking fashion with the superior articular facets
directed posteriorly and the inferior articular facets directed
anteriorly.
AXIAL BONE CT
First of 6 axial bone CT images presented from superior to
inferior through the cervical spine starting at the C4-C5 level
is shown. The cup-shaped intervertebral disc of the cervical
region is seen centrally, bounded along the posterolateral
margin by the uncinate processes. The uncinate process
defines the joint of Luschka between adjacent vertebral
segments. The neural foramina exit at ~ 45° in an
anterolateral direction, bounded posteriorly by the superior
articular process.
Image through inferior margin of intervertebral disc is
shown. The gracile pedicles arise obliquely from the
posterolateral margins of the vertebral bodies. The bony
canal is large relative to the posterior elements and
assumes a triangular configuration.
Image through C5 body level is shown. The transverse
process contains the transverse foramen for the vertebral
artery.
Image through mid C5 body at the pedicle level is shown.
The transverse foramina are prominent at this level with the
round, sharply marginated transverse foramen
encompassing the vertical course of the vertebral artery.
The anterior and posterior tubercles give rise to muscle
attachments in the neck. The vertebral body is interrupted
along the posterior cortical margin for the passage of the
basivertebral venous complex.
Image at the inferior C5 body level is shown. The uncinate
process arising off of the next inferior vertebral body is
coming into view. The inferior margins of the transverse
processes are incompletely visualized. The spinous process
is well seen, joining with the thin lamina.
View at the C5-C6 level shows the next neural foraminal
level bounded by the uncovertebral joint anteriorly and facet
posteriorly.
CORONAL CT MYELOGRAM
First of 3 coronal reformatted images from a CT myelogram
displayed from posterior to anterior is shown. The most
posterior view shows the spinal cord with exiting nerve
rootlets at each segmental level traversing in a craniocaudal
direction within the thecal sac. T1 transverse process is
prominent and directed superolaterally.
More anterior view shows the ventral margin of the cervical
spinal cord with the anterior median sulcus, which would
contain the anterior spinal artery. The ventral nerve rootlets
are also visible. The articular pillars of the facet joints are
well shown, giving a view similar to an AP radiograph of the
undulating lateral margin of the cervical pillars.
More anterior view shows transverse processes with
adjacent neural foramina. The posterior margins of the
vertebral bodies show the midline basivertebral veins.
SAGITTAL CT MYELOGRAM
First of 3 sagittal reformatted images from a CT myelogram
is shown. Paramedian sagittal section through the articular
pillar shows the facet joints in profile. Superior articular
facets are directed posteriorly, while inferior facets are
directed anteriorly. The curvilinear shape of the
atlantooccipital joint is visible, allowing for flexion/extension.
More medial section through obliquely oriented neural
foramina is shown. The neural foramina are bounded above
and below by pedicles, anteriorly by the uncovertebral joint,
disc, and vertebral body and posteriorly by the facet joint
complex.
Midline section shows the spinal cord outlined by the high
attenuation of the contrast within the cerebrospinal fluid.
Vertebral alignment is normal and prevertebral soft tissues
demonstrate an abrupt "shelf" at ~ the C4-C5 level where
the esophagus begins.
SAGITTAL T1 MR
First of 3 sagittal T1 MR images viewed from lateral to
medial is shown. View through the articular pillar shows the
facet joints in profile. Margins of the facet joints are well
corticated and seen as thin hypointense lines.
More medial section through obliquely oriented neural
foramina is shown.
Midline image shows the well-defined, low-signal cortical
margins of the vertebral bodies, which merge along their
anterior and posterior margins with the hypointense anterior
and posterior longitudinal ligaments, respectively. Vertebral
marrow signal is hyperintense relative to intervening discs
on T1 MR. Cerebrospinal fluid is hypointense.
SAGITTAL T2 MR
First of 3 sagittal T2 MR images viewed from lateral to
medial is shown. View through the articular pillars shows
normal alignment of the facet joints. The rhomboidal
configuration of the cervical facets is noted with their
complementary superior and inferior articular facets. The
exiting spinal nerves run in the groove along the superior
aspect of transverse processes.
More medial section shows the overlapping facets at each
level and the flow void of the vertebral artery within the
transverse foramen.
Midline image shows the relationship of the cervical cord,
vertebral bodies, and spinous processes with smooth
straight margins and alignment. The posterior dural margin
merges with the ligamentum flavum and spinous process
cortex low signal. The anterior dural margin merges with the
posterior body cortex and posterior longitudinal ligament.
AXIAL T1 C+ SPGR MR
First of 12 axial contrast-enhanced 3D T1-weighted
gradient-echo MR images extending from superior to
inferior beginning at the C1 anterior arch level is shown.
Carotid and vertebral arteries are subtle due to the contrast
enhancement. The horizontal segment of V3 is present
extending superiorly over the posterior arch of C1 (not
visible).
Image at the posterior arch of the C1 level and through the
odontoid process of C2 is shown. Vertebral arteries in the
transverse foramen are apparent and the enhancing internal
vertebral venous plexus (a.k.a. epidural veins) are also
seen.
Image at the C2 body level shows the short C2 pedicle and
the beginning of the C2 pars interarticularis. Vertebral
arteries are exiting from the transverse foramen.
AXIAL T1 C+ SPGR MR
Image at the C2-C3 level is shown. The C2-C3 foramen is
fully visualized with enhancing foraminal plexus and vertebral
arteries. The inferior articular process of C2 is shown prior
to visualization of the superior articular process of C3.
Dorsal nerve roots are visible along the posterior lateral
aspect of the cord.
Image through the C2-C3 disc level is shown. The
uncovertebral joints are seen along the posterior lateral
aspect of the disc margin. The C2-C3 facet joints are
coming into view with the widely patent neural foramen seen
anteriorly.
Image through the superior aspect of the C3 body is shown.
The transverse foramen containing the vertebral arteries are
prominent along the anterior aspect of the vertebral body.
Thin pedicles are seen extending posteriorly to the article
pillars.
Image thought the superior aspect of the C3-C4 disc is
shown. The dorsal and ventral nerve roots are well
identified extending toward the neural foramen. The neural
foramen show enhancement related to the foraminal venous
plexus and the anterior vertebral artery.
Image through the central aspect of the intervertebral disc
with the uncovertebral joints along the posterior lateral
margin separating the disc from the neural foramen is
shown. Nonenhancing nerves are outlined as linear lower
signal within the enhancing neural foramen.
Image though the superior endplate of C4 shows the
relationship of the exiting nerve root to the vertebral artery
at the distal aspect of the neural foramen.
Image at the mid C4 body level shows the relationship of
the pedicle with the transverse foramen and vertebral
artery. Enhancing internal vertebral venous plexus is well
defined, surrounding the thecal sac.
Image through the level of the C4 pedicles shows the thin
and gracile nature of the cervical pedicles. Pedicles extend
posteriorly to the articular pillar and the well-defined
posterior lamina.
View at the inferior portion of the C4 body shows a widely
patent right neural foramen and partial volume averaging of
the left pedicle and adjacent foramen. Within the thecal sac,
the ventral and dorsal roots are well visualized.
AXIAL T2 GRADIENT-ECHO MR
First of 6 axial T2* GE images from superior to inferior,
beginning at the level of the C2 body, is shown. The internal
vertebral venous plexus surrounding the thecal sac is
prominent, showing increased signal. This venous plexus is
contiguous with the more superior suboccipital cavernous
sinus at the C0-C1 level and contiguous with the more
inferior internal plexus (epidural).
Image at the mid C2 body level shows the short pedicles
and the beginning of the pars interarticularis. The dural
margin of the thecal sac is well-defined anteriorly, and the
anterior internal vertebral venous plexus shows high signal.
Image at the C2-C3 disc level is shown. The facet joints are
well defined and form the posterior boundary of the widely
patent neural foramen. The spinal cord shows the typical H
pattern of the central gray matter. The anterior median
fissure of the cord is visible at this level.
Image at the C2-C3 disc level is shown. The neural foramen
is well visualized, as are the ventral roots extending
laterally. The dentate ligament is visible on the left,
extending laterally from the cord to the lateral dural margin.
Image at the C3 body and pedicle level is shown. The
transverse foramen containing the vertebral arteries is well
defined. The articular pillars are prominent laterally.
Image at the inferior C3 body level at the junction with the
C3-C4 neural foramen is shown. The ventral and dorsal
nerve roots are very well defined, extending out toward the
neural foramen.
Thoracic Spine
Main Text
T ERM INOLOGY
Abbreviations
• Costovertebral (CV)
Synonyms
• Costal facet = demifacet
GROSS ANATOMY
Overview
• Consists of 12 vertebrae (T1-T12)

• Thoracic kyphosis
1 of 2 primary spinal curves (thoracic and sacral) present
at birth, maintained throughout life
Cervical and lumbar lordoses are secondary curves, more
flexible and result of development
– Considerable variability in amount of kyphosis (20-
45°)
– Each body contributes 3.8° of kyphosis via wedge-
shaped angulation
– Apex at T7
– Increases with age
–M<F
• Thoracolumbar junction
Transition from rigid thoracic spine to more mobile
lumbar spine
T11, T12 ribs provide less rigidity compared to rest of
thoracic spine
No connection to sternum (free floating)
Only single rib articulation on vertebral bodies
• Thoracic spine unique features
Articulation with rib cage
Coronal facet orientation
Small spinal canal relative to posterior element size
Components
• Bones
Thoracic vertebrae increase in size from T1 → T12
Body
– Typical body contains 2 costal demifacets laterally
– T1 has complete facet superiorly and demifacet
inferiorly, T10 has superior demifacet only, T11 and
12 have complete facet
Arch
– Pedicle: Projects directly posteriorly
– Transverse process: T1 transverse process projects
superolaterally; T1-T10 transverse process costal
facet articulates with costal tubercle
– Articular processes: Superior and inferior articular
process with coronally oriented facet joint
– Lamina
– Spinous process: T1-T9 project inferiorly; T10-T12
project more horizontally
• Interv ertebral foramen
Oriented laterally below pedicle
• Joints
Intervertebral disc
– Facets oriented near vertical in coronal plane
– Limit flexion and extension
Rib articulations
– CV joint : Rib head articulates with 2 costal
demifacets; superior costal facet of same number
vertebrae as rib and inferior costal facet of adjacent
cranial vertebral body
– Costotransverse joint : Transverse process of
vertebral body T1-T10
• Muscles
Superficial muscles include trapezius, rhomboid,
latissimus dorsi, and serratus inferior and superior
Deep muscles include erector spinae (sacrospinalis),
iliocostalis, longissimus, spinalis and semispinalis
thoracis, multifidus, rotatores, and interspinalis
• Ligaments
Anterior and posterior longitudinal, interspinous,
supraspinous ligaments, and ligamentum flavum
CV ligaments
– Radiate ligament connects head of rib and adjacent
vertebral bodies
– Costotransverse ligaments (lateral and superior)
connect neck of rib with transverse process
• Biomechanics
Intact rib cage increases axial load resistance 4x
Rib cage and facets limit rotation
IMAGING ANATOMY
Radiography
• Short C7 transverse process projects inferolaterally; long T1
transverse process projects superolaterally
MR
• Body: Signal intensity of marrow varies with age

Hemopoietic ("red") marrow is hypointense on T1WI,
becomes hyperintense with conversion from red →
yellow (age: 8-12 years)
End-plate, reactive marrow changes normally with aging
(can be fibrovascular, fatty, or sclerotic)
• Intervertebral disc: Signal intensity varies with age
Hyperintense on T2WI in children, young adults;
progressive ↓ water → hypointense on T2WI
Disc degeneration, desiccation, shape change (bulge)
normal after 2nd decade
• Ligaments: Hypointense on both T1WI and T2WI

Questions
• Thoracic spinal cord is protected and shielded from injury

by paraspinal muscles and rib cage
• Narrow spinal canal of thoracic spine allows for easy cord
compression with malalignment or trauma
• Normal kyphotic posture increases risk of fracture
• Thoracolumbar junction at more traumatic risk due to lack
of rib cage stabilization
Imaging Pitfalls
• Cervicothoracic junction
Cervical ribs arising from C7 found in 0.5% population
Short C7 transverse process projects inferolaterally
Long T1 transverse process projects superolaterally
Image Gallery
Print Images
GRAPHICS
Lateral view of thoracic vertebral body shows the

characteristic features of this spinal segment. The unique
superior and inferior demifacets form a concavity spanning
the intervening disc to house the rib head and form the
costovertebral joint. The spinous process is typically long
and oblique.
Graphic of thoracic vertebral body, viewed from above, is

shown. The thoracic bodies are characterized by long
spinous processes and transverse processes. The complex
rib articulation includes both costotransverse joints and
costovertebral joints. The facet joints are oriented in a
coronal direction.
Sagittal graphic through the thoracic vertebral foramen is
shown. The exiting nerve is positioned superiorly, bounded
by the vertebral body anteriorly, the pedicle above, and the
facet joint posteriorly. The facet joints are oriented in a near
coronal plane in the thoracic spine.
RADIOGRAPHY
AP view of the thoracic spine is shown. The square thoracic
vertebral bodies are aligned in the midline with symmetrical
paired and sharp corticated ovals of the pedicles. The
endplates are well defined with smooth intervertebral discs.
The spinous processes also align in the midline with the tips
extending to the next inferior level. The rib heads articulate
with the 2 adjacent vertebra (T5 rib articulates with T4 and
T5 bodies).
Lateral view of the thoracic spine is shown. The vertebral
bodies are identified with sharp cortical margins on all 4
sides, well-defined intervertebral disc spaces, and a gentle
thoracic kyphotic curvature. The neural foramina are well
identified on this projection. The posterior elements are ill
defined, due to considerable overlap of the right- and left-
sided ribs.
First of 3 coronal reformat images from a CT myelogram
through the thoracic spine presented from posterior to
anterior is shown. The posterior spinal canal is identified
with the intrathecal contrast, bounded laterally by the pairs
of medial ribs/pedicles seen as well-defined, corticated,
oval, bony densities. With the normal thoracic kyphosis, the
superior and inferior thoracic spine is seen in more anterior
section than the midportion.
More anterior CT through midcanal level is shown. The
relationship of the neural foramen, pedicle, and adjacent
medial rib is identified.
More anterior CT through the posterior vertebral body level
is shown. The costovertebral joint articulations are
particularly well identified in this view. Note the superior and
inferior costal facets (demifacets) with the rib head at disc
level.
3D-VRT NECT
Oblique anterior 3D-VRT examination of the thoracic spine
is shown. The complex costovertebral and costotransverse
joints are highlighted in the projection. The superior and
inferior demifacets are identified with the joint proper
crossing the intervertebral disc space.
Lateral oblique 3D-VRT examination of the thoracic spine is
shown. The relationship of the neural foramen and the
posterior elements and costal joints is visualized in this
projection. The foramen is bounded posteriorly by the facet
joint, superiorly by the pedicle, and ventrally by the posterior
margin of the vertebral body.
Lateral 3D-VRT examination of the thoracic spine is shown.
The neural foramina are oriented laterally and therefore
viewed en face in this projection bounded by the vertebral
body anteriorly, pedicle superiorly, and facet joint
posteriorly.
Left posterior oblique 3D-VRT examination of the thoracic
spine is shown. The facet joints are partially seen in this
projection, primarily obscured by the posterior surface of
the inferior articular facet, which overlaps the dorsal surface
of the superior articular facet from the next caudal vertebra.
The thoracic spinous processes are long and directed
inferiorly, overlapping the next vertebral body level.
Posterior 3D-VRT examination of the thoracic spine is
shown. The posterior bony projections of the thoracic spine
are highlighted in this projection, including the spinous
processes, transverse processes, and costotransverse
articulations.
Axial 3D-VRT examination of the thoracic spine is shown.
The 2 costal articulations are viewed in this projection. The
neural foramen are immediately adjacent to the
costovertebral articulations.
AXIAL BONE CT
First of 6 axial bone CT images presented from superior to
inferior at intervertebral disc level is shown. Neural foramina
are directed laterally and bounded anteriorly by the
posterior vertebral body margin and dorsally by the facet
joint (superior articular facet). The facet joints are oriented
in a coronal plane and strongly resist rotation combined with
the costovertebral joints.
CT through the pedicle level of the thoracic spine is shown.
The coronal orientation of the facet joints are well identified
in this section. The pedicles are relatively thin and gracile
with the adjacent rib articulations.
CT through vertebral body level is shown. The posterior
bony projections are highlighted in this view, including
spinous process, transverse processes, and medial ribs.
CT through the mid vertebral body level is shown. The
posterior vertebral body is pierced by the basivertebral
veins in the midline. The thoracic pedicles are gracile,
leading to large obliquely oriented transverse processes
supporting the costotransverse joints for the ribs.
CT through the neural foraminal level of the thoracic spine is
shown. The large neural foramina are directed laterally. The
orientation of the transverse processes is posterior and
lateral, as shown.
CT at the intervertebral disc level is shown. Neural foramina
are directed laterally and bounded anteriorly by the
posterior vertebral body margin and dorsally by the facet
joint (superior articular facet). The facet joints are oriented
in a coronal plane and strongly resist rotation combined with
the costovertebral joints.
SAGITTAL CT MYELOGRAM
First of 3 sagittal reformat images from a CT myelogram
presented from medial to lateral is shown. The slightly off
midline alignment allows for visualization of the midline
spinous processes of the superior thoracic spine and the
more lateral lamina and facet joints of the inferior thoracic
spine.
The oblique alignment again allows for visualization of the
lamina of the upper thoracic spine with the midline spinous
processes visible in the lower thoracic segment. The
vertebral bodies are square with well-defined cortical
margins and relatively thin intervertebral discs.
The upper thoracic segment demonstrates the pedicles
extending into the superior and inferior articular facets. The
laterally directed neural foramen, bounded by vertebral
body, pedicle, and facet, are evident.
SAGITTAL T1 MR
First of 3 sagittal T1 MR images of the thoracic spine
presented from medial to lateral is shown. The posterior
supporting ligamentous structures are identified on this
view, including the interspinous ligaments, ligamentum
flavum, and supraspinous ligament. The anterior longitudinal
ligament shows low signal, which is merged into the low
signal of the anterior vertebral body cortical margin.
The neural foramina are highlighted by high-signal foraminal
fat content containing the exiting nerve. The posterior,
coronally oriented facet joints are evident.
The costovertebral joint articulations are viewed as oblong-
shaped areas of marrow signal along the posterior disc
margins.
SAGITTAL T2 MR
First of 3 sagittal T2 MR images of the thoracic spine
presented from medial to lateral is shown. The square
thoracic vertebral bodies with the small intervening
intervertebral discs are identified in this midline view. The
spinous processes are large and dominate the dorsal soft
tissues. The thoracic cord is seen in its entirety with its
smoothly tapering conus medullaris.
The facet joints are identified on this sagittal MR with the
coronally oriented joints seen in the lateral view. The
superior and inferior articular processes and neural foramen
are easily viewed in this plane.
The more lateral margin of the neural foramen are identified
on this section as well as the costovertebral joints at the
disc levels. Participants of the costovertebral joint include
the inferior demifacet of the superior vertebral body, the
head of the rib, the superior demifacet of the vertebral body
inferior to the disc, which is of the same number as the rib,
and the intervertebral disc.
AXIAL T2 MR
First of 3 axial T2 MR images of the thoracic spine
extending inferiorly from the T6-T7 disc level is shown. This
MR through the disc level shows the coronal orientation of
the facet joints, forming the posterior boundary of the neural
foramen. The components of the intervertebral disc are
shown in this section with well-defined nucleus pulposus
showing high signal.
The relationship of the medial rib forming the strong
costotransverse and costovertebral joints is highlighted. The
transverse processes extend out dorsally and laterally to
articulate with the medial ribs. The spinous process is large
and directed caudally.
MR through the foraminal level of the thoracic spine is
shown. The neural foramina are directed laterally with their
posterior margin formed by the facet joints and anterior
margin by the vertebral body and disc.
Lumbar Spine
Main Text
T ERM INOLOGY
Abbreviations
• Anterior longitudinal ligament (ALL)

• Posterior longitudinal ligament (PLL)
Synonyms
• Articular processes = facets = zygapophyses
GROSS ANATOMY
Overview
• 5 discovertebral units (L1-L5)
Components
• Bones
Body
– Large, oval, cancellous ventral mass
– Larger in transverse width than AP diameter
Endplates
– Formed by superior and inferior surfaces of vertebral
bodies
– Consist of concave surfaces of 1-mm thick cortical
bone and hyaline cartilage plates
– Endplates are transitional between fibrocartilage disc
and vertebral body
– Nutrients to disc diffuse via endplates
Arch
– Pedicle: Project directly posteriorly
– Transverse process: Extend out laterally, long and
flat on L1-L4, small at L5
– Articular process: Superior and inferior articular
processes with pars interarticularis between; facet
joints oriented obliquely
– Lamina: Broad, thick, overlap minimally
– Spinous process
• Intervertebral foramen
Aperture giving exit to segmental spinal nerves and
entrance to vessels
Oriented laterally below pedicle
Boundaries
– Superior and inferior pedicles of adjacent vertebrae
– Ventral boundary is dorsal aspect vertebral body
above and intervertebral disc below
– Dorsal boundary is joint capsule of facets and
ligamentum flavum
Vertical elliptical shape in lumbar region
– Vertical diameter 12-19 mm
– Transverse diameter from disc to ligamentum flavum
~ 7 mm, thus little room for pathologic narrowing
• Joints
Intervertebral disc
– Outer annulus fibrosus (alternating layers of collagen
fibers)
– Inner annulus fibrosus (fibrocartilaginous
component)
– Transitional region
– Central nucleus pulposus (elastic mucoprotein gel
with high water content)
– Facet joints oriented obliquely
– Superior facet: Concave, faces dorsomedially to meet
inferior facet from above
– Inferior facet: Faces ventrolaterally to meet superior
facet from body below
• Ligaments
Anterior and posterior longitudinal ligaments,
interspinous and supraspinous ligaments
Ligamentum flavum
– Thick in lumbar region
– Connects adjacent lamina
– Extends from capsule of facet joint to junction of
lamina with spinous process, discontinuous in
midline
• Muscles
Erector spinae: Poorly differentiated muscle mass
composed of iliocostalis, longissimus, spinalis
Multifidi (best developed in lumbar spine)
Deep muscles: Interspinalis, intertransversarii
Quadratus lumborum and psoas muscles
• Biomechanics
Lumbar articulations permit ventral flexion, lateral
flexion, extension
Facets prevent rotation
Lumbosacral junction motion checked by strong
iliolumbar ligaments
IMAGING ANATOMY
Radiography
• Scotty dog sign demonstrated on oblique view

• Scotty dog sign demonstrated on oblique view
Nose = transverse process, eye = pedicle, ear = superior
articular process, neck = pars interarticularis, front leg =
inferior articular process
Cross-Sectional Imaging
• Facet joint orientation

Facet joint angle is measured relative to coronal plane
Normal facet joint angle ~ 40°
More sagittally oriented facet joints (> 45°) at L4 and L5
levels ↑ incidence of disc herniation and degenerative
spondylolisthesis

Imaging Pitfalls
• Lumbosacral junction
Transitional lumbosacral vertebrae
– Congenital malformation of vertebrae, usually last
lumbar or 1st sacral vertebra
– Bony characteristics of both lumbar vertebrae and
sacrum
Vertebral facet asymmetry ( tropism )
– Asymmetry between left and right vertebral facet
(zygapophyseal) joint angles
– Tropism defined as mild (6-10°), moderate (10-16°),
or severe (> 16°)
– Variable relationship between facet joint tropism and
disc herniation at L4 and L5 level
Image Gallery
Print Images
GRAPHICS
Graphic of lumbar vertebral body from above with a section

passing through the facet (zygapophyseal) joints is shown.
The large lumbar vertebral body is wider from side to side
than in the AP dimension. The pedicles are strong and
project directly posteriorly from the upper part of the body.
The central vertebral canal is triangular (cervical > lumbar >
thoracic). The spinous process is thick, broad and projects
backward. The superior articular facets are concave and
face posteromedially; the inferior articular facets are convex
and face anterolaterally.
Oblique graphic shows the characteristic Scotty dog
appearance of the superior (ear) and inferior (front leg)
articular facets with the intervening pars interarticularis
(neck). The well-defined superior and inferior articular
processes project respectively upward and downward from
the junctions of the pedicles and laminae.
Sagittal graphic of the lumbar spine through the neural
foramen shows the position of exiting nerves within the
superior aspect of the neural foramen. The segmental
vessels are located inferior to the exiting nerve. Neural
foramina are bounded anteriorly by the dorsal vertebral
body above and intervertebral disc below, the pedicle
above, and the facet joint and ligamentum flavum
posteriorly. The lumbar vertebral bodies are large with a
large intervening intervertebral disc. The pedicles are
directed posteriorly, giving rise to large superior and inferior
articular facets.
Coronal graphic, posterior view cutaway through the
pedicles of the lumbar spine shows exiting nerve roots
passing below their respective pedicles surrounded by the
nerve root sheath.
RADIOGRAPHY
AP view of the lumbar spine shows the lumbar bodies are
large and rectangular in shape with relatively thick
intervertebral disc spaces. The pedicles are viewed en face
with the adjacent facet joints incompletely visualized due to
their obliquity. The large, horizontal transverse processes
are easily identified at the pedicle levels.
Lateral view of the lumbar spine shows the large, strong
lumbar bodies join with the stout lumbar pedicles and
posterior elements. The neural foramina are large and
directed laterally. The boundary of the neural foramen
includes the posterior vertebral body, inferior and superior
pedicle cortex, and superior articular process.
Oblique view of the lumbar spine shows the typical Scotty
dog appearance of the posterior elements. The neck of the
dog is the pars interarticularis.
3D-VRT NECT
Left anterior oblique 3D-VRT NECT examination of the
lumbar spine is shown. The broad, stout pedicle/vertebral
body junction is highlighted in this projection with the
superior facet arising as the dorsal extension.
Left lateral 3D-VRT NECT examination of the lumbar spine
shows the neural foramen en face as it projects laterally.
Left posterior oblique 3D-VRT NECT examination of the
lumbar spine shows the surface anatomy inherent in the
Scotty dog sign. The transverse process (nose), superior
articular process (ear), inferior articular process (front leg),
and intervening pars interarticularis (neck) are well defined.
The pedicle, which forms the "eye" on oblique radiographs,
is obscured. The oblique sagittal orientation of the facet
joints is evident in this view, restricting lumbar rotation and
allowing flexion/extension.
Anterior 3D-VRT NECT examination of the lumbar spine,
with superior angulation, is shown. The large intervertebral
disc space is identified, in contrast to the cervical or
thoracic segments.
Superior view of 3D-VRT NECT examination of the lumbar
spine is shown. The large surface area of the posterior
elements with their dorsal projections is evident, allowing
broad muscle attachments.
Posterior view of 3D-VRT NECT examination of the lumbar
spine is shown. The "H" shape of the dorsal elements is
apparent in this projection. The superior arms of the "H" are
formed by the superior articular processes. The horizontal
bar reflects the lamina and spinous process. The inferior
arms of the "H" are the inferior articular processes.
AXIAL BONE CT
First of 6 axial bone CT images through the lumbar spine
presented from superior to inferior is taken at the
intervertebral disc and lower neural foraminal level. The
posterior intervertebral disc forms the lower anterior border
of neural foramen, which primarily contains fat. Exiting
nerves are in the upper neural foramen.
Image through facet joints is shown. The facet joint shows
typical lumbar morphology, with the superior facet showing
a concave posterior surface and inferior facet showing the
complementary convex anterior surface. Facet joints are
oriented ~ 40° from the coronal plane. An angle of > 45°
from the coronal plane increases the incidence of disc
herniation and degenerative spondylolisthesis at L4 and L5
levels.
This image shows the triangular central vertebral canal and
posteriorly oriented pedicles. The basivertebral veins enter
the vertebral body through the posterior cortex.
Image at the midvertebral body level shows a thick, cortical
vertebral body margin and midline posterior basivertebral
veins. The pedicles are strong, thick, and directed
posteriorly. Large transverse processes project from the
lateral margins.
Image at the endplate level shows the neural foramen,
opening laterally. The posterior elements have a T pattern
with the large, posteriorly directed spinous process.
Image through the intervertebral disc level again
demonstrates the lower neural foramen bounded anteriorly
by the intervertebral disc and posteriorly by the superior
articular process and facet joint. Oblique coronal orientation
of facet joints is again appreciated. Asymmetry between the
left and right vertebral facet joint angles with 1 joint having a
more sagittal orientation than the other is termed tropism.
SAGITTAL T1 MR
First of 3 sagittal T1 MR images of the lumbar spine
presented from medial to lateral is shown. The normal
marrow signal on T1 images is of increased signal
compared to the adjacent intervertebral discs in the adult,
due to fatty marrow content. The basivertebral veins are
seen as signal voids in the midline of the posterior vertebral
bodies, often with surrounding high-signal fatty marrow. The
intervertebral disc morphology is poorly identified on this
sequence with little differentiation of the annulus or nucleus.
In this image the lateral vertebral bodies are evident with
the pronounced oblong-shaped inferior articular facets
dominating the posterior aspect.
In this image the anterior boundaries of the neural foramina
are evident as is the relationship of the disc to the exiting
nerve.
1.5T AXIAL T1 MR
First of 3 axial T1 MR images of the lumbar spine presented
from superior to inferior is shown. This superior view shows
the thick, broad pedicles extending into the posterior
elements. The transverse processes are large, providing
surface area for muscle attachment.
Image though the upper neural foraminal level shows the
neural foramina are directed laterally, bounded anteriorly by
the posterior vertebral body and intervertebral disc and
posteriorly by the facet complex. Exiting peripheral nerves
are surrounded by hyperintense fat within the neural
foramen.
Image at the intervertebral disc and lower neural foramen
level is shown. The facet joints are well-defined in this plane
and are oriented ~ 40° from the coronal plane. The spinal
canal assumes a triangular configuration with the ventral
disc margin and the dorsal ligamentum flavum.
3T AXIAL T1 MR
First of 3 axial T1 MR images of the lumbar spine obtained
at 3T presented from superior to inferior is shown starting
at L3. This image shows the L3 pedicles merging into the
superior articular facet of L3. Medial to the facet joint
proper are the inferior articular processes of L2 and part of
the L2 spinous process.
This image shows the level of the neural foramen, outlined
by high signal intensity fat. The L3 inferior articular
processes are present, extending into the lamina and
spinous process.
Image through the L3-L4 disc level shows the midportion of
the facet joints and the L3 spinous process.
3T AXIAL T1 C+ FS MR
Series of 3 axial T1-weighted MR images with contrast and
fat suppression is shown extending from superior to inferior
at the L3 body level. Heterogeneous signal in the pedicles is
due to ghosting artifact from the more anterior vasculature.
Axial image at the level of the neural foramen is shown.
There is heterogeneous enhancing within both foramen due
to the enhancing foraminal venous plexus and nonenhancing
exiting nerve roots. Inferior articular processes, lamina, and
spinous process of L3 are well defined.
Axial image through the more inferior aspect of the neural
foramen shows the pronounced normal enhancement of the
dorsal root ganglion. Prominent enhancing veins are also
seen within the foramen.
CORONAL T1 MR
First of 6 coronal T1 MR images through the lumbar spine
presented from posterior to anterior is shown. The posterior
elements are visualized in this section, with the lateral
margins of the facet joints in view.
More anterior image of the lumbar spine is shown. The
dorsal (posterior) ramus of the L4 nerve is demonstrated
surrounded by fat passing posteriorly, following its exit
through the neural foramen. Midline epidural fat is seen as a
linear band separating the paired ligamentum flavum.
More anterior image of the lumbar spine is shown. The L3
nerve is seen extending underneath the L3 pedicle. The
spinal nerve ganglia are surrounded by fat within the neural
foramen. Distal to the ganglion, the spinal nerve divides into
anterior and posterior branches. Posterior branches supply
motor innervation to the deep muscles of the back and
sensation to skin of the back.
More anterior image of the lumbar spine shows the
relationship of exiting nerves to the pedicles. Nerves exit the
foramina in an inferior lateral direction at the same
numbered pedicle level (i.e., L5 root exits below L5
pedicle).
The junction of the vertebral bodies with the ventral epidural
space is highlighted in this view. The posterior longitudinal
ligament is seen as a dark, vertically oriented band in the
midline. The adjacent epidural fat shows high signal. The
vertebral bodies are defined by the superior and inferior
endplates.
This is the most anterior image of the lumbar spine. The
vertebral body endplates are visualized for each segment
with the intervening thick intervertebral disc.
1.5T AXIAL T2 MR
First of 6 axial T2 MR images of the lumber spine presented
from superior to inferior is shown. This view through the
intervertebral disc shows increased disc signal within the
central nucleus pulposus due to its high water content and
low signal within the peripheral annulus fibrosus. The margin
with the thecal sac is sharp, with the cauda equina seen as
punctate nerves within the high-signal cerebrospinal fluid.
The L3 nerve is extraforaminal in location, the L4 nerve is
transiting in the lateral recess.
Image just below the L4 pedicle shows the exiting L4 nerve
passing just below the pedicle within the upper neural
foramen.
This image shows the L4 nerve ganglion and surrounding fat
within the mid neural foramen. The posterior margin of the
neural foramen at this level is facet joint complex, and the
anterior margin is the posterior vertebral body
3T AXIAL T2 MR
Image through L2-3 intervertebral disc is shown. The typical
facet morphology is identified. The superior articular facet is
seen as a concave anterior bony mass with low-signal
cortical margin. The joint space is seen as a linear focus of
high signal due to joint fluid and cartilage. The inferior
articular facet is typically convex anteriorly, although it can
be seen as a straighter margin or even slightly concave.
Image through the upper L3 neural foramina shows exiting
L3 nerves just below the pedicles (with partial volume
averaging of the pedicles).
Image through the more inferior L3-4 foramen shows the
dorsal root ganglia bilaterally.
Sacrum and Coccyx
Main Text
T ERM INOLOGY
Definitions
• Sacrum: Large triangular bone formed from 5 fused

vertebrae at base of vertebral column
GROSS ANATOMY
Overview
• Sacrum
Consists of 5 fused vertebrae (S1-5)
Large, triangular shape, forms dorsal aspect of pelvis
3 surfaces: Pelvic, dorsal, and lateral
Base: Articulates superiorly with L5
Apex: Articulates inferiorly with coccyx
• Coccyx
Consists of 3-5 rudimentary fused segments
Components of Sacrum
• Bones
Central body, lateral sacral ala, posterior triangular-
shaped sacral canal
4 paired ventral and dorsal sacral foramina extend
laterally from sacral canal to pelvic and dorsal surfaces,
respectively
Pelvic surface
– Concave, forms dorsal aspect of pelvis
– 4 paired anterior sacral foramina
– 4 transverse ridges between anterior sacral foramina
Dorsal surface
– Convex
– Median sacral crest in midline ~ fused spinous
processes
– Sacral groove on either side of crest
– Intermediate sacral crest lateral to groove ~ fused
remnants of articular processes
– 4 paired posterior sacral foramina are lateral to
intermediate crest
– Lateral sacral crest lateral to foramina ≈ remnants of
transverse processes
– Sacral hiatus : Dorsal bony opening below
termination of median sacral crest
Lateral surface
– Broad upper part, tapers inferiorly
– Ventral articular surface for sacroiliac joint and
dorsal roughened area for ligamentous attachment
• Joints
Lumbosacral junction
– Joins with 5th lumbar vertebra by L5-S1 disc and
facet joints
– Superior base articulates with L5
– Superior articular processes of S1 faces dorsally
Sacrococcygeal joint
– Apex of sacrum and base of coccyx
– Contains fibrocartilaginous disc
Sacroiliac joints
– Ventral synovial joint
Between hyaline covered articular surface of
sacrum and fibrocartilage covered surface of
iliac bone
– Dorsal syndesmosis: Interosseous sacroiliac ligament
• Soft tissues
Thecal sac
– Thecal sac terminates at S2 level in majority of
subjects
– Wide variation at level of termination, from L5
inferior body level to S3
– Extradural component of filum terminale continues
from S2 to attach at 1st coccygeal segment
Nerves
– Sacral canal contains sacral and coccygeal nerve
roots
– Nerves emerge via ventral and dorsal sacral foramina
Muscles
– Piriformis : Arises from ventral sacrum, passes
laterally through greater sciatic foramen to insert on
greater trochanter; nerves of sacral plexus pass
along anterior surface of piriformis muscle
– Gluteus maximus, erector spinae, and multifidus
arise from dorsal sacrum
Ligaments
– Anterior longitudinal ligament passes over sacral
promontory
– Posterior longitudinal ligament on dorsal surface of
lumbosacral disc forming ventral margin of bony
canal
– Sacroiliac joint secured by broad anterior,
interosseous and posterior sacroiliac ligaments
– Sacrospinous ligament bridges lateral sacrum to
ischial spine
– Sacrotuberous ligament bridges lateral sacrum to
ischial tuberosity
IMAGING ANATOMY
Overview
• Lumbosacral junction
Transitional vertebrae
– 25% of normal cases
– Sacralization of lumbar body
Spectrum from expanded transverse processes
of L5 articulating with top of sacrum to
incorporation of L5 into sacrum
– Lumbarization of sacrum
Elevation of S1 above sacral fusion mass
assuming lumbar body shape
Sacrum lies at 40° incline from horizontal at lumbosacral
junction
– Axial load result in rotational forces at LS junction
– Rotation forces checked by sacrotuberous,
sacrospinous ligaments

Imaging Pitfalls
• Lumbarization and sacralization may appear similar, require

counting from C2 caudally to precisely define anatomy
Image Gallery
Print Images
GRAPHICS
Anterior graphic shows the sacrum, a large, fused bony
mass of 5 vertebra forming the posterior aspect of the
pelvis. The superior articular facets arise off of the sacrum
and articulate with the inferior articular processes of L5 to
form the lumbosacral junction.
Axial graphic through the sacrum is shown. The sacrum is
highlighted as 3 bony masses, with the central body and
lateral sacral ala. The ventral and dorsal sacral foramina
are visible arising from the central sacral canal, extending to
the pelvic and dorsal surfaces, respectively.
Coronal graphic shows the relationship of the sacrum to the
sacral nerve plexus. The upper and lower sacral bands of
the sacral plexus are depicted. The primary terminal branch
of the upper sacral band is the sciatic nerve, which consists
of the lumbosacral trunk and the first 3 ventral sacral
nerves. The lower sacral band forms the pudendal nerve to
the perineum.
Sagittal graphic depicts the upper and lower bands of the
sacral plexus in anatomic relationship to the musculature of
the pelvic bowl. The upper sacral bands coalesce into the
sciatic nerve on the ventral surface of the piriformis muscle.
3D-VRT NECT
Anterior 3D-VRT NECT of the sacrum is shown. The
sacrum is seen as a large, fused bony mass of 5 vertebra
forming the posterior aspect of the pelvis. The multiple
sacral roots exit via the 4 paired sacral foramen. The
superior aspect of the sacrum articulates with the inferior
endplate of L5.
Anterior oblique 3D-VRT NECT of the sacrum is shown. The
superior aspect of the sacrum, with the broad sacral ala
and the sacral promontory, are highlighted in this projection.
Posterior 3D-VRT NECT of the sacrum is shown. The
dorsal sacrum has vertically oriented ridges, which are
homologous to the more cephalad spinal column. The
median sacral crest is homologous to the spinous
processes. The intermediate sacral crest is analogous to
the facets. The lateral sacral crest is analogous to the
transverse process.
AXIAL T2 MR
First of 6 axial T2 MR images of the sacrum presented from
superior to inferior is shown. The lumbosacral facet
articulations are visible between the functioning anterior
positioned superior articular process of S1 (which faces
medially and dorsally), articulating with the posterior
positioned inferior articular facet of L5.
Axial T2 MR through the S1 body is shown. At this level, the
sacral body and sacral ala are seen as one large bony
mass extending between the lateral sacroiliac joints.
Posteriorly, the median crest of the sacrum is prominent.
Axial T2 MR more inferiorly through the S1/S2 junction is
shown. The exiting ventral and dorsal S1 nerves are seen
passing through the ventral and dorsal foramina,
respectively.
Axial T2 MR through the S2 body is shown. At this level, the
sacral body and sacral ala are again seen as one large
bony mass extending between the lateral sacroiliac joints.
The sacroiliac joints consist of a ventral synovial joint and a
dorsal syndesmosis bridged by the interosseous sacroiliac
ligament. The thecal sac has terminated at this level (S2)
and the sacral canal now only contains peripheral lower
sacral and coccygeal nerves, fat, and extradural portion of
filum terminale. Note incidental spina bifida.
Ventral S2 nerves are seen exiting anteriorly.
Section through lower sacrum demonstrates piriformis
muscle arising from lateral sacrum and extending laterally
through greater sciatic foramen. Note the large sciatic nerve
on the anterior surface of the piriformis muscle.
AXIAL NECT
First of 3 axial NECT images through the sacrum presented
from superior to inferior is shown. Bony components of the
sacrum include the central body, paired lateral ala, and
dorsal sacral canal. The different components of the
sacroiliac joints are seen. The ventral synovial and dorsal
syndesmosis are evident.
More inferior image through the sacrum shows 1 of the 4
paired ventral sacral foramina where the S1-S4 ventral
sacral nerves exit into the pelvis.
Image through the mid-sacrum shows one of the paired
dorsal sacral foramina.
ANTERIOR RADIOGRAPH & CORONAL NECT

Anterior radiograph of the sacrum shows paired sacroiliac
joints on either side of the triangular sacrum, composed of 5
fused sacral vertebrae. The ventral sacral foramina are
clearly outlined by a corticated superomedial margin and an
indistinct inferior margin.
Coronal NECT through the sacrum is shown. The paired
ventral sacral foramina are evident. The broad sacroiliac
joint is identified. The fused 5 sacral segments are visible in
the midline.
More posterior image through the sacrum is shown. The
ventral sacral foramina are seen at various degrees of
obliquity, giving a variety of appearances from circular to
rectangular.
CORONAL T1 MR
First of 6 coronal oblique T1 MR images through the sacrum
presented from posterior to anterior is shown. The dorsal
and ventral sacral foramina are readily identified by the
target appearance of cortical bone, foraminal fat, and
central nerve. The sacrum and coccyx are partially identified
due to the sacral and coccygeal curvature.
Image at the junction of the dorsal foramen and the exiting
ventral roots is shown.
Image through the beginning of the ventral foramen is
shown, with well-defined exiting sacral nerves surrounded
by foraminal fat.
Image through the mid-sacrum is shown. The paired ventral
sacral foramina are evident with their rounded foci of high-
signal fat with central low-signal exiting roots. The broad
sacroiliac joint is identified as low signal separating the
sacral ala from iliac wings (ilium). The fused sacral
segments are visible in the midline.
Image through the ventral sacral foramen shows the
rounded, low-signal exiting nerves as well as multiple
adjacent vascular flow voids, primarily related to foraminal
veins. The SI joint is well identified with iliac and alar
components.
Image through the most ventral aspect of the sacral
foramen is shown, with partial visualization of the pyriformis
muscle.
CORONAL T2 FS MR
First of 3 T2 fat-saturated (FS) coronal oblique MR images
through the sacrum extending from posterior to anterior is
shown. The thecal sac and exiting roots are well defined,
showing high signal, with suppression of the foraminal fat
and adjacent fatty bone marrow.
Section through the mid-sacrum shows the exiting roots at
the S1-3 levels. The SI joints and adjacent bone marrow are
low signal, which allow for easy identification of joint
pathology that would be hyperintense.
Image through the more anterior aspect of the ventral
neural foramen is shown, with high signal intensity exiting
nerves.
LATERAL RADIOGRAPH & SAGITTAL T2 MR

Lateral radiograph shows the sacrum and lumbosacral
junction. The sacrum consists of 5 fused vertebrae with
pelvic, dorsal, and lateral surfaces. It articulates at its base
with L5, at its apex with the coccyx, and laterally with the
iliac bones bilaterally. The anterior margin of the S1 body is
termed the promontory and forms the posterior margin of
the pelvic inlet.
Sagittal midline T2 MR of the sacrum is shown. The typical
lumbosacral junction morphology is present, with well-
defined L5-S1 intervertebral disc, square shape of L5, and
trapezoidal shape of S1. Rudimentary sacral intervertebral
discs are seen as linear low signal. Note the thecal sac
termination at the S2 level.
SECT ION 2
CORD, MENINGES, AND SPACES
Outline

Spinal Cord and Cauda Equina
Main Text
T ERM INOLOGY
Abbreviations
• Spinal cord (SC)

• Cauda equina (CE)
Definitions
• Tract: Nerve fibers with shared origin, destination, or

function
• Root: Coalescence of rootlets into dorsal (sensory), ventral
(motor) roots
• Nerve: Union of dorsal, ventral roots
• Ganglion: Aggregation of cell bodies, nerve fibers
GROSS ANATOMY
Overview
• SC
Suspended within thecal sac
Anchored to dura by denticulate ligaments
Long, tapered, cylindrical conduit between medulla,
peripheral nervous system
2 enlargements
– Cervical enlargement (C3-T2) with maximum
diameter at C6
– Lumbar enlargement at T9-T12
Cord tapers to diamond-shaped point (conus medullaris)
Conus normally ends between T12 to L2-L3 interspace
(T12-L1 most common level)
External landmarks
– Deep ventral (anterior) median fissure extends along
entire ventral surface
– Dorsal (posterior) median sulcus is more shallow
– Posterolateral sulcus (dorsal rootlets enter cord here)
– Ventrolateral sulcus (ventral rootlets emerge from
cord here)
Internal landmarks
– In contrast to brain, gray matter is on inside with
white matter on periphery of cord
– Central gray matter formed by columns ("horns") of
neuronal cell bodies; is roughly H-shaped
Anterior, posterior gray commissures connect 2
near-vertical arms of "H"
Ventral (anterior) horn of "H" is shorter, thicker,
and contains multipolar motor neurons
Dorsal (posterior) horn is longer, more narrow,
and receives sensory axons from dorsal root
ganglions (DRGs)
Small lateral horn only found between T2, L1
cord segments
– 3 white matter columns (funiculi): Dorsal, ventral,
lateral
Descending motor, ascending sensory tracts
mostly in lateral, ventral funiculi
Fibers for position sense, discriminative touch in
dorsal funiculi
– Ependymal-lined central canal
• Filum terminale
Strand of connective tissue extending inferiorly from
conus
Fuses distally into dura, attaches to dorsal coccyx
• Spinal nerve roots
8 cervical (1st exits between skull base, C1), 12 thoracic, 5
lumbar, 5 sacral, 1 coccygeal
Paired dorsal, ventral roots exit from their respective
hemicords
Descend separately across subarachnoid space (SAS),
dura, then unite in/near intervertebral foramina
Ventral roots contain mostly efferent somatic, some
sympathetic fibers
Dorsal roots mostly contain afferent axons (both somatic,
visceral)
Lose pia at dorsal root ganglia level
• CE
"Horse's tail" of lumbar, sacral, coccygeal nerve roots
below conus
IMAGING ANATOMY
Overview
• SC
T1WI: H-shaped, central gray matter hypointense
compared to myelinated (hyperintense) white matter
T2WI: Gray matter relatively hyperintense compared to
myelinated white matter
Maximal cord diameter in axial section varies with
location
– Up to 75% at cervical enlargement
– Generally 50% or less in thoracic region, except for
slight ↑ at thoracic enlargement
Filum terminale
– Normally 2 mm or less in diameter
– Has distal branch of anterior spinal artery, which
normally enhances
• Spinal nerve roots
Course becomes longer, more oblique at caudal levels
Intrathecal nerve roots have blood-nerve barrier; do not
normally enhance
DRG has no blood-nerve barrier; enhances normally
• CE
On axial T2WI, normally lie in U-shaped configuration
within thecal sac

Questions
• Somatotopic cord organization predicates clinical findings,

pathology
• Central gray matter = cord watershed zone
• Conus is at normal "adult" level at birth
• Multiplanar T2WI best demonstrates cord, roots

• T2 FSE or CISS sequence for "MR myelogram" effect
Imaging Pitfalls
• Sagittal plane less reliable than axial for determining conus

position
• Pulsatile cerebrospinal fluid (CSF) flow, spin dephasing
often causes "flow voids" and should not be mistaken for
vascular malformation
Image Gallery
Print Images
GRAPHICS
Sagittal graphic of the cervical spinal cord is shown. The

central spinal cord canal is contiguous with the obex, the
inferior point of the 4th ventricle. The transition from the
obex to the central canal of the spinal cord is marked by the
dorsal "bump" of the nucleus gracilis, which is easily seen
on sagittal T2 MR scans through the craniocervical junction.
Axial graphic depicts internal anatomy of the distal thoracic
spinal cord. The deep ventral median fissure divides the
ventral hemicords, while the smaller dorsal median
sulcus/septum divides the dorsal hemicords. The dorsal
intermediate sulcus separates the dorsal funiculus into
gracile and cuneate tracts. The dorsal and ventral nerve
roots arise from the dorsolateral and ventrolateral sulci,
respectively.
Coronal graphic through the middle of the spinal canal
shows the distal thoracic spinal cord and nerve roots of the
cauda equina. Note the cord ends in a diamond-shaped
point, the conus medullaris. Lumbar nerve roots exit the
thecal sac just under the pedicles of their same-numbered
vertebral segments. The filum terminale is a strand of
connective tissue that extends inferiorly from the conus to
the dorsal coccyx. It normally contains no functional neural
tissue and no fat.
Sagittal graphic of the thoracolumbar junction demonstrates
normal conus and cauda equina anatomy. The filum
terminale lies among the cauda equina roots and affixes the
conus to the terminal thecal sac.
First of 3 coronal CT myelograms presented from posterior
to anterior demonstrates the dorsal (sensory) roots
surrounded by dense cerebrospinal fluid.
This image depicts the spinal cord within the thecal sac. The
central spinal cord canal may imbibe myelographic contrast
in some cases (especially on delayed scans), although, in
this case, the high density in the central cord represents
partial volume averaging with the ventral median fissure.
Note that CT provides little information regarding the internal
cord structure due to its limited contrast resolution.
This image shows the ventral spinal cord and ventral
(motor) nerve roots and dense contrast opacified
cerebrospinal fluid (CSF) within the ventral median fissure.
First of 3 coronal reformatted images from a CT myelogram
through the thoracic spine presented from posterior to
anterior is shown. The posterior spinal canal is identified
with the intrathecal contrast, bounded laterally by the pairs
of medial rib/pedicles seen as well-defined corticated oval
bony densities. With the normal thoracic kyphosis, the
superior and inferior thoracic spine is seen in the more
anterior section than the mid portion.
More anterior image through the midcanal level is shown. In
the thoracic spine, the cord typically occupies ~ 50% of the
subarachnoid space.
Image through the posterior vertebral body level is shown.
The conus medullaris is well seen here. There is a slight
expansion of the distal thoracic spinal cord before it tapers
into its diamond-shaped point, the conus.
SAGITTAL T2 AND CORONAL STIR MR

Sagittal T2 MR demonstrates the entire spinal cord from the
cervicomedullary junction to the conus. The cauda equina is
draped dependently within the caudal thecal sac. Although
the patient is imaged supine, it is typical for the normal
thoracic spinal cord to be anteriorly positioned and conus
posteriorly positioned in the thecal sac because of the
normal kyphotic thoracic and lordotic lumbar curvature.
First of 2 coronal STIR MR images demonstrates the cauda
equina roots somatotopically organized within the caudal
thecal sac. The nerve roots are arranged with the more
rostral (lumbar) levels laterally and the caudal (sacral,
coccygeal) levels medially.
A more ventral image shows the lumbosacral spinal nerves
exiting through their named neural foramina.
AXIAL CISS AND T2 MR

Axial CISS sequence provides bright, homogeneous CSF
signal intensity. The hypointense bilateral denticulate
ligaments anchor the spinal cord to the dura. The dorsal and
ventral roots are resolved as separate structures within the
thecal sac, and join at the neural foramen to produce the
proper spinal nerve.
First of 2 axial T2 MR images shows the normal cervical
spinal cord gray and white matter clearly delineated. The
intermediolateral gray matter column representing the cell
bodies of the sympathetic nervous system is only present in
the thoracolumbar spinal cord and not seen at the cervical
level.
Image of the conus demonstrates normal conus anatomy.
The peripheral white matter and central gray matter are
easily distinguished. Note the characteristic bump of the
intermediolateral column of the sympathetic nervous
system.
AXIAL T2 MR
First of 3 axial T2 MR images at the L1 foraminal level
shows the conus tip and cauda equina. At this level, the
ventral and dorsal nerve roots of the cauda equina are
separately positioned ventrally and dorsally, respectively,
within the thecal sac.
This image at the mid L2 level reveals the cauda equina
nerve roots moving laterally in preparation to form the spinal
nerve proper and exit through the appropriate neural
foramen. Note that the ventral roots remain ventral and
dorsal roots dorsal.
This image at the L4 level shows the nerve roots losing their
ventral/dorsal orientation in order to congregate near the
lateral thecal sac in preparation to form the appropriate
spinal nerves. At this and lower levels, the roots assume a
U-shaped configuration around the margins of the thecal
sac.
LONGITUDINAL ULTRASOUND
First of 3 longitudinal ultrasounds shows the normal
hypoechoic spinal cord with hyperechoic central echo
complex. Contrary to popular misunderstanding, this central
echo complex is a reflection of echoes from the interface
between the ventral white commissure and CSF within the
ventral median fissure rather than from the central canal.
Image centered more caudally best demonstrates the
hypoechoic spinal cord terminating as the conus. The
hyperechoic cauda equina drapes around the conus and
undulates with each CSF pulsation during real-time
observation.
This image demonstrates the mildly hyperechoic filum
terminale anchoring the spinal cord to the terminal thecal
sac. The cauda equina nerve roots drape dependently
within the thecal sac.
TRANSVERSE ULTRASOUND
First of 2 transverse ultrasounds demonstrates the
hypoechoic conus surrounded by hyperechoic cauda equina
nerve roots. The central echo complex is well visualized.
A more caudal image shows the hypoechoic cauda equina
suspended within CSF. The filum is positioned centrally
within the cauda equina.
Meninges and Compartments
Main Text
T ERM INOLOGY
Definitions
• Meninges = collective term for dura, arachnoid, pia

Pachy ("thick") meninges = dura
Lepto ("thin") meninges = arachnoid, pia
• Spaces = real or potential spaces between meningeal layers
or adjacent structures
• Ligaments = suspend spinal cord within thecal sac
• Compartments = anatomic construct for location-based
imaging differential diagnoses
GROSS ANATOMY
Overview
• Meninges
Dura
– Dense, tough outermost layer of connective tissue
– Only 1 dural layer in spine
– Attached by fibrous bands to posterior longitudinal
ligament
– Tubular prolongations (nerve sheaths) of
dura/arachnoid extend around roots/nerves through
intervertebral foramina, terminate near dorsal root
ganglia (DRG)
– Dura fuses with epineurium of spinal nerves distal to
DRG
Arachnoid
– Thin, delicate, continuous with cranial arachnoid
– 2 layers: Outer (loosely attached to dura),
intermediate (attached to pia)
Pia
– Delicate, innermost layer of meninges
– Closely applied to cord, spinal nerves
• Ligaments
Denticulate ligaments
– Flat, fibrous, serrated sheets that support spinal cord
– Collagenous core is continuous with pia
– Extend laterally from pia along each side of cord,
between ventral/dorsal roots
– Insert into dura mater
Dorsal, dorsolateral, ventral spinal cord ligaments
– Thin, irregular, fenestrated; extend from cord to
arachnoid
Septum posticum
– Incomplete longitudinal midline membrane
– Connects pia/cord dorsally to dura
– Partially divides subarachnoid space (SAS), creating
"pseudocompartments"
• Spaces
Epidural space (extradural compartment)
– Between dura and surrounding vertebral canal
– Extends from foramen magnum to posterior
sacrococcygeal ligament
– Contains fat, loose connective tissue, small arteries,
veins, lymphatics
Subdural space
– Potential space between dura, outer surface of
arachnoid
SAS
– Between inner surface of arachnoid, pia
– Contains CSF, vessels, spinal cord ligaments, nerves,
filum terminale
– Continuous with intracranial SAS
Subpial space (potential space only)
• Compartments
Extradural compartment
– Epidural space
– Vertebral bodies, neural arches, intervertebral discs,
paraspinous muscles
Intradural extramedullary compartment
– SAS
– Spinal cord ligaments, nerve roots, cauda equina,
filum terminale
Intramedullary compartment
– Spinal cord, pia
IMAGING ANATOMY
Overview
• Meninges
Dura
– Thin black line on T2WI
– Vessels lack endothelial tight junctions so dura
enhances strongly, uniformly
Arachnoid
– Normally adheres to dura; not visualized separately
• Ligaments
Seen as thin, linear "filling defects" on T2WI
• Spaces
Spinal CSF isointense with intracranial CSF
Questions
• Localization of lesion to specific anatomic compartment

greatly assists imaging differential diagnosis
• Position of spinal needle for lumbar puncture, myelography
should be in SAS
Spinal needles are beveled, may "tent" arachnoid as they
are pushed through dura
May result in "split" injection (mixed subarachnoid,
subdural contrast)
Subdural injection usually localized
Epidural injection results in "epidurogram" with contrast
spreading freely in epidural space, along nerve roots
• T2 weighted, CISS sequences best for "MR myelogram"

• Nicely demonstrate spinal meninges, ligaments, outline
cord/roots
Imaging Pitfalls
• Denticulate ligaments, septum posticum create

"pseudocompartments" where CSF may flow at different
rates, directions
• Spin dephasing → "flow voids" in CSF; should not be
mistaken for vascular malformation
Image Gallery
Print Images
GRAPHICS
Sagittal graphic of the thoracic level shows the relationship
of the central cord and surrounding meninges within the
vertebral canal. The thick dura defines the intra- and
extradural compartments. Extradural compartment contains
primarily fat and veins. Arachnoid is closely adherent to
inner dura creating the potential subdural space.
Subarachnoid space contains CSF, which surrounds the
spinal cord, and is continuous with intracranial subarachnoid
CSF cisterns. Pia mater is closely adherent to the surface
of the cord.
Coronal cutaway graphic demonstrates the relationship
between the dura and nerve roots. Note the nerve
root/sleeve exit spinal canal just under the pedicle of the
same numbered level.
Cutaway graphic of the spinal cord and its coverings
demonstrates the meningeal layers and their relationship to
the adjacent regional structures.
Axial graphic demonstrates cross-sectional anatomy of the
spinal canal and its meningeal layers. Nerve root sleeves
are directly contiguous with the dura mater, which joins the
peripheral nerve epineurium lateral to the neural foramen.
Arachnoid lines root sleeves. The web-like tissue within the
subarachnoid space represents the inner trabecular portion
of the arachnoid mater. The denticulate ligaments arise
between the dorsal and ventral spinal nerve roots and
anchor the spinal cord laterally to the dura mater of the
thecal sac.
AXIAL CT MYELOGRAM
First of 3 axial CT myelogram images through the thoracic
spine, presented from superior to inferior in a patient with a
CSF leak, is shown. Contrast injected into the subarachnoid
space has leaked into the extradural compartment and, as a
result, beautifully demonstrates the dura surrounded on both
sides by contrast material.
The ventral and dorsal nerve roots are seen traversing the
subarachnoid space toward the dural nerve root sleeve,
which is an outpouching of dura and arachnoid.
The dural nerve root sleeve containing the exiting nerve is
seen extending laterally toward the neural foramen
surrounded by CSF in the extradural compartment. Dura of
the nerve root sleeve is directly contiguous with the
peripheral nerve epineurium lateral to the neural foramen.
The dorsal nerve root exiting at the next level down is seen
within the subarachnoid space.
LONGITUDINAL AND TRANSVERSE ULTRASOUND

First of 2 longitudinal US images in a normal infant
demonstrates the hypoechoic conus medullaris surrounded
by hyperechoic cauda equina nerve roots. The hyperechoic
dura defines the margins of the thecal sac filled with
anechoic CSF. The arachnoid dura mater complex of the
thecal sac corresponds to the echogenic border of the
spinal canal dorsal and ventral to the subarachnoid space.
This image demonstrates the mildly hyperechoic filum
terminale anchoring the spinal cord to the terminal thecal
sac at the S2 level. The cauda equina nerve roots drape
dependently within the thecal sac.
Transverse US shows the normal conus and its coverings
suspended within the CSF-filled thecal sac.
Longitudinal US demonstrates anechoic CSF within the
extradural (epidural) potential space. The extradural
effusion developed following lumbar puncture with CSF leak.
The extradural fluid separates the hyperechoic dura from
normally adjacent hyperechoic dorsal extradural fat.
Transverse US demonstrates CSF within the dorsal
extradural (epidural) potential space. The extradural
effusion developed following lumbar puncture with CSF leak.
SAGITTAL AND AXIAL CT MYELOGRAM

Sagittal CT reformat following myelography with
unintentional administration of the entire contrast bolus into
the extradural space is shown. The thecal sac terminates at
around S2 in the normal position. Contrast is leaking around
the dorsal extradural fat, confirming its localization in the
extradural space. A small L5/S1 disc protrusion is
incidentally noted.
Axial CT following inadvertent extradural administration of
contrast demonstrates the extradural space. Contrast
surrounds the unopacified thecal sac and dural nerve root
sleeves and leaks out through the neural foramina along the
nerve root sleeve. A similar appearance would be
intentionally produced following contrast injection during
therapeutic extradural nerve root injection. The extradural
contrast also invaginates into the dorsal extradural fat,
confirming injection into the extradural space.
Sagittal CT reformat following myelography demonstrates
the subdural potential space, permitted by inadvertent
administration of intrathecal contrast into the subdural
space. There is ventral displacement of the arachnoid
without disruption of the dura.
Axial CT following myelography demonstrates the subdural
potential space, seen here because of a split injection of
intrathecal contrast into the subdural and subarachnoid
spaces. There is slight ventral displacement of the
arachnoid without disruption of the dura. The acute margins
within the thecal sac and lack of mixing with the
subarachnoid contrast confirms split injection partly into the
subdural space.
AXIAL T2 MR
Axial steady state free precession (CISS) MR of the upper
cervical spine shows the normal denticulate ligaments
anchoring the spinal cord laterally to the dura within the
subarachnoid space. The denticulate ligaments are found
between the ventral and dorsal nerve roots and are a
surgical landmark.
Axial T2 MR of the lower thoracic spine demonstrates
hypointense dura delineating the thecal sac and its bright
(CSF) contents. On T2 FSE MR, the CSF appears similar in
signal intensity to extradural fat.
Axial fat-saturated T2 FSE MR mostly negates fat signal
permitting visualization of the distal thecal sac (lumbar
cistern) and cauda equina. The CSF-filled, arachnoid-lined
dural root sleeves are noted adjacent to the thecal sac
preparing to exit through the neural foramina.
AXIAL T1 C+ MR, AXIAL AND CORONAL T1 MR

Axial T1 C+ fat-saturated MR of the cervical spine shows
intense but normal enhancement of venous plexus within the
extradural compartment outlining the isointense dura and
hypointense CSF. Extradural compartment contains
primarily fat and veins.
Axial T1 MR at the L1 level shows the hypointense dura
delineating the CSF-filled thecal sac surrounded by
hyperintense fat within extradural compartment. Also note
the fat surrounding the dorsal root ganglion within the neural
foramina bilaterally.
Coronal T1 MR shows the hypointense nerve root sheaths
(sleeve), which represent dural outpouchings (nerve root
sheath or sleeve) exiting via the neural foramina. The nerve
roots descend in the thecal sac as the cauda equina and
exit under the pedicle at their named levels. Bright signal
intensity fat defines the extradural space.
SECT ION 3
VASCULAR
Outline

Spinal Arterial Supply
Main Text
T ERM INOLOGY
Abbreviations
• Anterior, posterior spinal arteries (ASAs, PSAs)

• Vertebral artery (VA), basilar artery (BA)
Synonyms
• Great anterior segmental medullary artery = artery of

Adamkiewicz
GROSS ANATOMY
Vertebral Column, Epidural Soft Tissues
• Segmental arrangement
Arteries numbered for segments from which they arise
Numerous transverse, longitudinal anastomoses extend
over several segments
Cervical
– VAs (dorsal intersegmental anastomoses)
– Thyrocervical trunk (ventral intersegmental
anastomoses)
Thoracic
– Arise from paired intercostal arteries
– Pre-, postcentral branches to vertebral bodies
– Pre-, postlaminar, spinal branches to canal, neural
arch
Lumbar : Arise from paired lumbar segmental arteries
Dura, Cord, Roots, Nerves
• Spinal cord circulation derived from

VAs (ASA, PSA)
Segmental vessels at multiple levels; ascending cervical,
deep cervical, intercostal, lumbar, sacral
• ASA
Arises at junction of intradural segment of VAs
Lies in midline on ventral cord surface (in anterior
median fissure)
Courses inferiorly from foramen magnum to filum
terminale
Supplies anterior 2/3 of cord
– Anterior horns, spinothalamic/corticospinal tracts
– Penetrating (central) branches have few collaterals
Augmented by segmental feeders
• PSAs
Arise from posterior inferior cerebellar artery or posterior
rami of VA
Paired longitudinal channels on dorsal cord medial to
dorsal roots
Numerous plexiform anastomoses between PSAs
Supply posterior 1/3 of cord
– Posterior columns, some corticospinal tracts
(variable)
Augmented by medullary feeders from posterior
radicular arteries
• Segmental arteries
Dorsal rami of segmental arteries arising from vertebral,
subclavian, thoracic intercostal, lumbar intercostal
arteries
Enter canal through foramen, penetrate dura
– Radicular arteries in anterosuperior quadrant of
foramen in 96% of cases
Divide into dural, radiculomedullary branches
– Dural arteries supply dura, nerve root sleeves
– Radiculomedullary branches supply roots, cord
• Radiculomedullary arteries
Arise from dorsal segmental arteries, penetrate
subarachnoid space
Radicular branches supply anterior/posterior roots
Medullary branches anastomose with ASA/PSA, provide
variable supply to cord
• Cervical
Major radicular feeders between C5-7 level
2-3 anterior cervical cord feeders
3-4 posterior cervical cord feeders
• Thoracic
Anterior thoracic cord feeders ~ 2-3
– Usually left sided
– Small ventral feeders may also be present
– Inverse relationship between number, caliber of
ventral radicular vessels
– "Paucisegmental": Fewer vessels (< 5) with larger
caliber
– "Plurisegmental": More vessels with smaller caliber
Dominant thoracic anterior radicular = artery of
Adamkiewicz
– Left-side origin (73%)
– T9-12 origin (62%)
– Lumbar origin (26%)
– T6-8 (12%)
Upper thoracic cord feeding vessel between T3-T7 =
artery of von Haller
Posterior thoracic cord feeders ~ 9-12 (average 8)
– No right-left lateralization preference
– Vessel caliber: 150-400 µ
– Variable reporting of "great posterior radicular
artery"
• Lumbosacral and pelvic
0-1 major cord feeders
ASA ends at conus, gives communicating branches
("rami cruciantes") to PSAs
Artery of Desproges-Gotteron = "cone artery" arising
from iliac extending to L5 or S1 nerve roots and up to
conus
Posterior division of iliac artery → inferior and superior
lateral sacral branches → spinal arteries via anterior
sacral foramina
Anterior division of iliac artery → inferior gluteal
artery → supplies sciatic nerve
Posterior division of internal iliac artery → iliolumbar
artery supplies femoral nerve at iliac wing level
• Cord nutrient vessels
Central and peripheral systems
Central → ASA and flow centrifugal
Peripheral → PSA, pial plexus and flow centripetal
Dense capillary network in gray matter of cord
IMAGING ANATOMY
Overview
• Artery of Adamkiewicz has characteristic "hairpin" turn on

imaging (DSA, CTA, MRA)
• Hypotensive infarcts affect central gray matter
• ASA infarct affects anterior 2/3 of cord
• Evaluation of vascular malformations must visualize entire
spinal vasculature (VAs to iliac)
Image Gallery
Print Images
GRAPHICS
AP graphic shows the aortic arch and arterial great vessels

in red. The vertebral arteries give rise to the anterior and
posterior spinal arteries (ASAs and PSAs). The ascending
cervical arteries, branches of the thyrocervical trunks, give
off anterior and posterior segmental medullary arteries that
anastomose with the ASA and PSA on the cord surface.
Complete spinal angiography includes evaluation of all these
vessels.
Oblique axial graphic rendering of T10 depicts segmental

intercostal arteries arising from the lower thoracic aorta.
The artery of Adamkiewicz is the dominant segmental
feeding vessel to the thoracic cord, supplying the anterior
aspect of the cord via the anterior spinal artery. Note its
characteristic "hairpin" turn on the cord surface as it first
courses superiorly, then turns inferiorly.
Axial graphic shows overview of the arterial supply to the

vertebral column and its contents, depicted here in the
lower thoracic spine. A series of paired segmental arteries
(cervical region arises from the vertebral and thyrocervical
arteries, thoracic region is intercostal arteries, and lumbar
region is lumbar arteries) divide into anterior and posterior
branches. The posterior branch gives rise to a muscular
branch, a branch to the vertebral body, and the
radiculomedullary artery. The radiculomedullary artery
enters the vertebral canal via the neural foramen.
Anterior and posterior radiculomedullary arteries

anastomose with the anterior and posterior spinal arteries.
Penetrating medullary arteries in the cord are largely end
arteries with few collaterals. The cord "watershed" zone is
at the central gray matter.
3D-VRT CECT
In the 1st of 6 3D-VRT angiographic images, AP volume-
rendered image of CTA shows the course of the vertebral
arteries entering the transverse foramen and ascending to
the foramen magnum. Both vertebral arteries in this patient
enter the C6 level, but this can show wide normal variation.
Lateral oblique volume-rendered CTA image of the cervical
spine shows the course of the vertebral artery within the
transverse processes. Note the ventral to dorsal course of
the artery as it ascends toward the transverse foramen of
C6. The distal vertebral artery makes a lateral course from
the foramen of C2 then ascends through the foramen of C1
where it turns posteriorly to pass over the posterior arch of
C1 to enter the foramen magnum.
Axial oblique image of the cervical CTA at the C2 level
shows the relationship of the vertebral artery to the
transverse foramen.
Cranial oblique view of volume-rendered CTA images shows
the vertebral arteries leaving the transverse foramen of C2
and coursing lateral to the lateral masses as they ascend
toward the transverse foramen of C1. The cut plane
extends superiorly through the lateral masses of C1 and
odontoid process of C2.
Cranial oblique view of CTA examination with cut plane
superior to the arch of C1 demonstrates the course of the
distal vertebral arteries as they exit the transverse foramen
of C1 and turn medial to extend over the posterior arch of
C1 to then ascend through the foramen magnum.
Lateral volume-rendered CTA shows the course of the
distal left vertebral artery passing through C1 and the
horizontally oriented transverse foramen of C2.
CT ANGIOGRAPHY
Coronal spinal CTA multiplanar reformat shows the anterior
spinal artery as a linear contrast enhancement along the
conus and proximal filum.
Right anterior oblique CTA volume-rendered image shows
the distal aorta giving rise to multiple segmental feeding
vessels extending around the right lateral margin of the
vertebral bodies toward the neural foramen.
Lateral volume-rendered image of spinal CTA shows the
close relationship of the segmental feeding vessels
extending posteriorly toward the neural foramen of the
thoracic spine and their intimate relationship with the
vertebral bodies.
AXIAL CT ANGIOGRAM
First of 3 axial CTA source images shows the arterial
supply to the spine via lumbar segmental arteries. Upper
section through the vertebral body and transverse
processes shows both right and left segmental arteries.
Note the basivertebral vein seen here as a funnel-shaped
area of contrast in the middle of the vertebral body,
connecting posteriorly to the epidural venous plexus.
Scan through the middle of the vertebral body shows
segmental vessels with a dorsal muscular branch seen
especially well.
Scan at level of the intervertebral disc space shows 2
dorsal muscular branches supplying the paraspinous
muscles adjacent to the lamina and posterior spinous
processes.
AP IA-DSA
Series of 3 IA-DSA images showing various appearances of
the artery of Adamkiewicz is shown. This AP IA-DSA
arterial phase image is from a right L1 lumbar artery
injection. The L1 lumbar artery gives rise to the major
segmental feeding vessel of the lower thoracic cord (artery
of Adamkiewicz). The artery of Adamkiewicz shows a
characteristic sharp turn as it joins the anterior spinal artery.
The caudal portion of the ASA is larger than the cephalic
extension.
AP IA-DSA late arterial phase of a T11 intercostal injection
shows the typical "hairpin" turn of the artery of
Adamkiewicz. The anterior spinal artery is present in the
midline as vertical arteries both superior and inferior to the
junction with Adamkiewicz.
AP IA-DSA arterial phase image from the left L1 lumbar
artery injection is shown. The artery of Adamkiewicz
ascends from the lumbar artery to supply the distal thoracic
cord and conus. The artery of Adamkiewicz shows a
characteristic sharp "hairpin" turn as it joins the anterior
spinal artery.
AP DSA
Series of 3 images demonstrating cervical cord arterial
supply is shown. This AP view of the right vertebral injection
shows a dominant segmental branch (artery of cervical
enlargement) supplying the cervical anterior spinal artery
and arising off the midcervical vertebral artery.
AP view of left subclavian artery injection shows a
prominent ascending cervical branch that supplies the
dominant segmental feeder to the cervical cord and the
anterior spinal artery. The left vertebral had a separate
origin from the aortic arch in this patient.
Coronal reformat of a neck CT angiogram shows the
radiculomedullary artery supplying the cervical anterior
spinal artery.
DSA AND CTA

AP view of a left T8 intercostal injection gives rise to the
characteristic "hairpin" turn of the major segmental feeding
vessel to the thoracic cord, the artery of Adamkiewicz.
Extending inferiorly from the top of the "hairpin" turn is the
anterior spinal artery, which supplies the anterior 2/3 of the
cord.
Sagittal CTA shows that the left T8 intercostal segmental
artery gives rise to the characteristic "hairpin" turn of the
major segmental feeding vessel to the thoracic cord, the
artery of Adamkiewicz. Extending inferiorly from the top of
the "hairpin" turn is the anterior spinal artery, which supplies
the anterior 2/3 of the cord.
AP view of right vertebral injection shows the anterior spinal
artery extending inferiorly from the right distal vertebral
artery. The anterior spinal artery is well seen due to
occlusion of the distal right vertebral artery with collateral
reconstitution of the basilar artery.
Spinal Veins and Venous Plexus
Main Text
T ERM INOLOGY
Abbreviations
• Vertebral venous system/plexus (VVS, VVP)

• Superior, inferior vena cava (SVC, IVC)
Synonyms
• Epidural plexus = Batson plexus
GROSS ANATOMY
Overview
• VVS
Large valveless network in/around vertebral column
Part of extradural neural axis compartment (EDNAC)
Extent: Sacral hiatus to foramen magnum
– Ends in clival plexus, suboccipital sinus
Extensive collaterals, anastomoses
– SVC and IVC (like azygos system)
– 3 major external complexes: Internal VVP,
basivertebral veins, external VVP
– Smaller intradural veins
Function
– Blood flows either direction, varies with
thoracic/abdominal pressure
– Large volume relative to arterial supply (20x greater)
• Internal VVP
Epidural venous network surrounds thecal sac
– Series of irregular, thin-walled valveless sinuses
– Arranged in ladder-like series of cross-connected
expansions up vertebral column
– Embedded in epidural fat
– Tributaries: Radicular veins, veins along posterior
elements
Anterior/posterior epidural regions
– Anterior more prominent
– Formed from 2 continuous channels along posterior
surface of vertebral bodies between pedicles
– Channels expand to cross anastomose with each
other, receive basivertebral veins
– Largest at central dorsal region of vertebral body
– Thinnest at disc level
• Basivertebral veins
Paired valveless intravertebral veins
Extend horizontally through anterior, posterior vertebral
bodies
Collect numerous small venous channels within vertebral
bodies
Drain into anterior internal VVP
Drain anteriorly into external VVP
• External VVP
Anterior, posterior components in paravertebral region
Surround vertebral column
Connect with: Internal VVP; azygos, lumbar veins ⇒
IVC, SVC
Posterior veins form paired system, lie in vertebrocostal
grooves
Cross anastomoses lie between spinous processes
Extensive in posterior nuchal region, drain into deep
cervical veins, IJV
• Intradural veins
Parallel spinal arteries
Symmetric pattern of venous drainage (compared with
highly asymmetric arterial supply)
– Minimal anterior-posterior, right-left, segmental
variations
Central, peripheral groups of radial veins drain into
anastomoses on cord surface
Central group provides return for anterior horns,
surrounding white matter
– ⇒ Drain into central veins in anterior median fissure
– ⇒ Form anterior median vein
Peripheral dorsal, lateral cord drainage via small
valveless radial vein plexus
– ⇒ Coronal venous plexus on cord surface
– ⇒ Epidural venous plexus of Batson
– Epidural plexus connects with SVC, IVC,
azygos/hemiazygos systems, intracranial dural
sinuses
30-70 medullary radicular veins
– No anterior or posterior dominance
– Anterior median vein continues caudally along filum
terminale to end of dural sac
Coronal, median veins drain ⇒ medullary veins
– No intradural valves but medullary veins have
functional valve-like mechanism at dural margin
– Prevents epidural reflux into intradural space
– Medullary veins leave intradural space at root sleeve
⇒ epidural plexus
IMAGING ANATOMY
Overview
• CT
Normal funnel-shaped discontinuity in cortex of
posterior vertebral bodies
Represents site at which basivertebral veins drain into
anterior internal VVP
• Spinal veins, plexi enhance strongly on T1 C+ MR
External, internal VVPs surround vertebral column,
thecal sac
Basivertebral vein enhances in "Y" configuration
Thin, linear enhancement on cord surface normal,
caused by venous anastomoses
Faint filum terminale enhancement normal

Questions
• Retrograde flow from pelvis → epidural plexus

Provides natural route of spread from pelvic neoplasms,
infection to vertebral bodies
• Pharyngovertebral veins penetrate anterior atlantooccipital
membrane ⇒ surround atlantoaxial joint
Permits inflammatory relaxation/subluxation (Grisel
syndrome)
Image Gallery
Print Images
GRAPHICS
Axial graphic of thoracic vertebral bodies and venous
anatomy is shown. The vertebral bodies are drained by
anterior perforating veins as well as via the basivertebral
venous plexus. The anterior perforating veins are part of the
anterior external plexus, while the basivertebral veins are
part of the anterior internal plexus. The spinal central canal
contains the anterior and posterior internal vertebral venous
plexi (VVP).
Magnified graphic of the internal VVP is shown. The
radicular veins course along the dorsal and ventral rami,
eventually draining into components of the anterior or
posterior internal plexus, and subsequently the segmental
veins, which will drain into the superior or inferior vena cava.
AXIAL T1 C+ MR
First of 6 axial T1 C+ FS MR images through the cervical
spine presented from superior to inferior shows the
distribution of the cervical venous plexus surrounding the
vertebral arteries and joining with the anterior and posterior
internal VVP. The posterior external plexus forms 2 parallel
columns of veins to either side of the spinous processes.
Image through C2 body shows the anastomoses between
the different venous components, such as the anterior
internal plexus and posterior external plexus dorsal to the
lamina and surrounding vertebral arteries.
Image through the C2-3 neural foramen shows the
prominent venous plexus surrounding vertically oriented
vertebral artery flow void, and anastomosing with the
internal venous plexus circumferentially surrounding the
thecal sac.
Image through more inferior aspect of the C2-3 neural
foramen shows the prominent venous plexus surrounding
vertically oriented vertebral artery flow void, and
anastomosing with thin crescentic internal venous plexus
circumferentially surrounding the thecal sac. The
communication between the posterior external vertebral
veins and the more anterior foraminal plexus is pronounced.
Image at C3 body level shows the typical pattern of epidural
enhancement due to the anterior internal venous plexus,
most prominent along lateral margins of the anterior canal
and thinning in the midline. The anastomoses of the plexus
surrounding the vertebral artery and the more ventral
anterior external plexus are shown.
Image through C3-4 level shows the marked enhancement
of the foraminal plexus, merging with the external plexus
lateral to the facets.
CORONAL T1 C+ MR
First of 6 coronal T1 C+ FS MR images is presented from
anterior to posterior. The course of the internal jugular veins
(IJVs) from the jugular bulb inferiorly are shown bilaterally,
and their relationship to the inferior petrosal sinus and
basisphenoid.
Image though the midodontoid level shows the inferior
petrosal sinus draining into the jugular vein and adjacent
hypoglossal canal with venous plexus. Anterior external
venous plexus of the upper cervical spine is defined by
diffuse enhancement along the course of the neural
foramina.
Section toward the posterior margin of the odontoid
process continues to define the relationship of the prominent
left jugular bulb with the hypoglossal canal and inferior
anterior external VVP.
Section through posterior margin of odontoid process
shows posterior margin of the jugular bulbs and hypoglossal
canals. The anterior internal VVP (anterior epidural plexus)
is now prominent and merges with the plexus within each
neural foramen.
Section through midportion of upper cervical canal shows
cerebral venous drainage extending to the skull base with a
prominent right sigmoid sinus. The venous plexus
surrounding the vertebral artery is present cephalad to the
enhancement of the internal venous plexus at C1-2.
Section through midportion of upper cervical canal shows
the cerebral venous drainage at skull base with transverse
and sigmoid sinuses curving along occipital bone. The
retrocondylar venous system is also present, merging with
the upper cervical external plexus.
AXIAL, SAGITTAL, & CORONAL CECT MIP

Axial CECT MIP image shows reflux of contrast into both
the external and internal venous plexus with opacification of
the left IJV.
Sagittal CECT MIP of cervical spine shows reflux
opacification of the venous system, including basivertebral
veins, and posterior external venous drainage surrounding
spinous processes.
Coronal CECT MIP projection shows reflux of contrast into
the anterior external and internal venous systems. The
anterior internal venous plexus assumes the typical
stepladder pattern crossing the midline at the mid vertebral
body level.
AXIAL & SAGITTAL CECT MIP

Series of CECT MIP projections of a neck CT following
intravenous contrast administration through the left arm vein
is shown. The 1st axial MIP image at cervicothoracic
junction shows reflux of contrast retrograde into the cervical
vertebral veins outlining both external and internal VVP
anatomy. The foraminal component of the external plexus
drain through multiple cervical muscular veins into the
subclavian system.
Axial CECT MIP image at the T1 level shows the anterior
internal vertebral veins crossing midline with the central
basivertebral veins. The drainage of the cervical veins
towards both left and right subclavian systems is
demonstrated.
Sagittal CECT MIP image through the left cervical facet
level shows the confluence of the external plexus along the
neural foramen, and the drainage towards the innominate
vein.
SECT ION 4
PLEXI AND PERIPHERAL NERVES
Outline

Brachial Plexus
Main Text
T ERM INOLOGY
Abbreviations
• Brachial plexus (BP)
Definitions
• Collection of interconnecting nerves of lower cervical spine

(C5-8) and 1st thoracic nerve (T1) that provide cutaneous
and motor innervation of upper extremity
GROSS ANATOMY
Overview
• Cervical cord
Internally, cervical spinal cord is arranged so that white
matter tracts are positioned in periphery of cord
Gray matter is formed by neuronal cell bodies arranged
in vertical columns that are centrally located within cord
Gray matter columns form H-shaped arrangement in
axial plane (in cross section) where lateral, sagittally
oriented components are referred to as horns and
transverse coronal components are referred to as gray
commissures
Ventral (anterior) horns of H are thicker, shorter, and
contain multipolar motor neurons
Dorsal (posterior) horns are thinner, longer, and contain
cell bodies that receive sensory axons from dorsal root
ganglions (DRGs)
• Cervical nerve rootlets, nerve roots, and proximal nerves
At each cervical level, ventral horns give rise to motor
axons that exit ipsilateral ventrolateral sulci of cervical
cord as several tiny (< 1-mm) nerve rootlets
Ventral nerve rootlets at each level coalesce within few
millimeters of cord to form as ipsilateral ventral root (~ 1
mm)
Similarly, dorsal horns receive multiple tiny nerve
rootlets at posterolateral sulcus of cord
Dorsal nerve rootlets also coalesce within few millimeters
of cord to form dorsal root
Dorsal root extends laterally from cord and merges with
DRG within neural foramen (NF)
Within lateral aspect of cervical NF, DRG fuses with
ventral root to become spinal nerve proper
Immediately after proper spinal nerve is formed, small,
posteriorly oriented dorsal ramus is given off, supplying
motor and sensory innervation to posterior paraspinous
muscles and cervical soft tissues
Larger remaining segment of spinal nerve represents
ventral ramus
– Since ventral ramus is typically main part of spinal
nerve in cervical region, it is often referred to as
simply spinal nerve itself
– These large ventral rami of nerves C5-T1 are also
referred to as roots of BP
1st cervical nerve exits spinal canal between occiput and
C1; that is, C1 nerve exits above C1 vertebra (atlas)
– C2 nerve exits between C1 and C2 vertebrae and so
forth
– C8 nerve exits between C7 and T1 vertebrae
• Cervical plexus
Formed from ventral rami of C1-4 ± minor branch of C5
Has ascending superficial, descending superficial, deep
branches
Supplies nuchal muscles, diaphragm, cutaneous
head/neck tissues
• BP
Formed from ventral rami of C5-T1 ± minor branches
from C4, T2
Has some proximal branches originating above BP
proper
– Dorsal scapular nerve
– Long thoracic nerve
– Nerves to scalene/longus colli muscles
– Branch to phrenic nerve
Remaining minor, all major peripheral branches arise
from BP proper
BP divided into anatomic segments moving from medial
to lateral: Rami/roots, trunks, divisions, cords, terminal
branches
– Relationships of these segments with adjacent
anatomic structures is variable
Ventral rami/roots of BP
– Originate from spinal cord levels C5 to T1
– Roots of BP represent ventral rami of nerves C5-T1
– Term "root" in this context is not to be confused with
nerve roots discussed previously, which represent
small nerves within spinal canal and within proximal
NF
– Some nerves arise directly from roots: Dorsal
scapular nerve (C5), phrenic (mainly C5), long
thoracic nerve (C5, 6, and 7)
Trunks
– Within interscalene triangle, upper roots of BP (C5-6)
fuse to form superior (upper) trunk
– Lower roots (C8-T1) fuse to form inferior (lower)
trunk
– C7 root continues laterally as middle trunk
– Minor nerves arising directly from upper trunk:
Suprascapular nerve, nerve to subclavius muscle
Divisions
– As BP passes laterally beyond interscalene triangle
over lateral margin of 1st rib and begins to descend
toward axilla, each trunk divides into 2 main nerve
branches: A nterior and posterior divisions
– Subsequently, each BP contains total of 6 divisions: 3
anterior and 3 posterior
– Anterior divisions innervate anterior (flexor) muscles
– Posterior divisions innervate posterior (extensor)
muscles
– No named minor nerves arising directly from
divisions
– Divisions are located at level of clavicle and above
junction of subclavian and axillary arteries
Cords
– As BP passes into axilla, divisions fuse again to form
cords
– Cords are intimately associated with axillary artery
and are named by their relationship to artery itself
– Lateral cord (anterior divisions of superior, middle
trunks) innervates anterior (flexor) muscles
– Medial cord (anterior division of inferior trunk)
innervates anterior (flexor) muscles
– Posterior cord (posterior divisions of all 3 trunks)
innervates posterior (extensor) muscles
Branches (terminal)
– Cords form terminal branches of BP at
approximately level of lateral margin of pectoralis
minor muscle
– Musculocutaneous nerve (C5-6) arises from lateral
cord
– Medial cord gives rise to ulnar nerve (C8-T1)
Medial cord also gives rise to medial pectoral
nerve, medial cutaneous nerve of arm, medial
cutaneous nerve of forearm
– Axillary nerve (C5-6), radial nerve (C5-T1),
thoracodorsal nerve (C6-8), upper (C6-7) and lower
(C5-6) subscapular nerves all arise from posterior
cord
– Median nerve (C5-T1) formed by confluence of
contributions from both medial and lateral cords
• NF
C5 nerve passes through NF at C4-5
– C6 nerve passes through NF at C5-6
– C7 nerve through C6-7 NF
– C8 nerve passes through NF at C7-T1
– T1 nerve passes through NF at T1-2
Within NF, most conspicuous neural structure is DRG,
bulbous enlargement of dorsal root
Within NF, nerves of C5, 6, and 7 are positioned
immediately posterior to vertebral artery
• Lateral neural sulcus
Transverse processes of C3-6 have similar anatomic
appearance with transverse foramen that transmits
vertebral artery and lateral neural sulcus (superolateral
groove of transverse process), where corresponding
cervical nerve is positioned
– e.g., after exiting NF at C4-5, C5 nerve descends and
passes laterally to lateral neural sulcus of transverse
process of C5 vertebra
When vertebrae of C3-6 are viewed in axial plane
through transverse process, vertebral artery is separated
from proximal ventral ramus by small bony bar that
separates transverse foramen from lateral neural sulcus
• Interscalene triangle
Anterior scalene muscle arises from anterior tubercles of
transverse processes of 3rd through 6th cervical
vertebrae and inserts on superior surface of 1st rib
anteriorly
Middle scalene muscle arises from posterior tubercles of
transverse processes of 2nd through 7th vertebrae and
attaches to 1st rib laterally
Borders of interscalene triangle
– Anterior border: Posterior margin of anterior scalene
muscle
– Posterior border: Anterior edge of middle scalene
muscle
– Inferior border (base): Superior margin of 1st rib,
between separate attachments for 2 muscles
– Interscalene triangle can also be considered 3-
dimensional space with both lateral and medial
borders as well
– Medial border is represented by plane extending
from medial margins of anterior and middle scalene
muscles and lateral border as plane between lateral
margins of both muscles
Widest portion of triangle is at base, along 1st rib
– Distance between attachments of anterior and
middle scalene muscles to ribs is ~ 1 cm (range: 1.0-
2.5 cm)
Interscalene triangle contains variable amounts of fat
– Interscalene fat is most conspicuous in lower aspect
of triangle
– More superiorly, anterior and middle scalene
muscles are closely approximated, and distinct fat
separating muscles may be minimal or absent
– Presence of fat, particularly perineural fat, is useful
for identifying proximal components of BP within
interscalene triangle on MR and CT scans
BP roots of C5-7 are located within upper aspect of
interscalene triangle and begin to form upper and
middle trunks as they pass through triangle itself
BP roots of C8-T1 are actually medial to triangle initially
and begin to form lower trunk as they enter medial
margin of interscalene triangle
Interscalene triangle is considered to contain upper,
middle, and lower trunks of BP
• Subclavian artery
Subclavian artery gives off vertebral artery and internal
thoracic artery before entering interscalene triangle
Subclavian artery passes through base of interscalene
triangle, passing just over superior margin of 1st rib
Within triangle, subclavian artery is intimately associated
with proximal BP
C5-7 roots are located superior to artery; C8 and T1 roots
are often more posterior to artery
Subclavian artery and BP are separated from subclavian
vein by anterior scalene muscle itself
Subclavian artery transitions to axillary artery at lateral
margin of 1st rib
• Axillary artery
As subclavian artery passes 1st rib, it becomes axillary
artery
Components of BP above proximal axillary artery
generally consists of anterior and posterior divisions
Divisions then form cords that are intimately associated
with axillary artery and are named by their relationship
to artery itself
Cords are generally formed prior to reaching sagittal
plane that passes through coracoid process of scapula
• Phrenic nerve
Arises primarily as branch from C4 ventral ramus with
variable contributions from C5 and occasionally C3
Passes around lateral margin of anterior scalene muscle
and descends in neck along anterior surface of anterior
scalene
Near base of anterior scalene muscle, phrenic nerve
passes between subclavian vein and subclavian artery
before passing anterior to internal thoracic artery and
entering mediastinum
Supplies motor and sensory innervation to diaphragm
IMAGING ANATOMY
Overview
• Knowledge of normal BP anatomy and relationship of BP

components to surrounding structures critical for evaluating
BP
• Multiplanar high-resolution MR using surface coil is single
best method for imaging BP
• Components of BP are complex and difficult to identify and
fully evaluate with single MR sequence or in single plane
• Surrounding perineural fat often provides excellent
visualization of nerves on T1WI and allows them to be
distinguished from adjacent soft tissues
• Corresponding T2WI, STIR sequences are best for evaluating
intrinsic signal and architecture of nerves
• Characteristics of normal nerve on MR
In cross section, nerve appears as well-defined oval
structure
Discrete fascicles can be identified with high-resolution
imaging
– Fascicles are uniform in size, shape
Isointense to adjacent muscle tissue on T1WI
Slightly hyperintense to adjacent muscle on fat-saturated
T2WI, STIR
Normal nerves should be similar in signal intensity
compared to adjacent normal nerves and contralateral
normal nerves
While DRG enhances with intravenous gadolinium,
major components of BP should not enhance normally

• Multiplanar high-resolution MR peripheral nerve imaging

using surface coil is single best method for imaging BP
• MR of cervical spine can be useful primary examination to
evaluate for spinal cord pathology as well as common
degenerative findings, including spinal stenosis and NF
stenosis, that create BP symptoms
• CECT of neck or chest may be useful for evaluation of neck
masses or apical pulmonary masses (Pancoast tumor) that
involve BP
• CT myelography can be effective tool at evaluating for
traumatic nerve root avulsion and associated traumatic
pseudomeningoceles
• CT of cervical spine with bone windows preferred for
cervical spine fracture
• CTA neck can demonstrate relationship of proximal BP
masses with vertebral arteries
• Ultrasonography is alternative imaging technique to
visualize small component of BP
Excellent spatial resolution provided by high-frequency
transducer
Seen as long, tubular, hypoechoic structures against
background of echogenic fat on longitudinal scan
Several small ovoid/round hypoechoic nodules in lower
posterior triangle between scalenus anterior and
scalenus medius muscles on transverse scan
Lack of flow distinguishes them from vascular structures
Imaging Approaches
• Preferred coil: Multipurpose flexible phase array surface coil

• Alternative coil: Neurovascular phase array coil
• Best imaging planes: Coronal and oblique sagittal planes
from C3 (rostral) through T2 (caudal), nerve roots (medial)
through axilla (lateral)
• Best imaging sequences: Coronal T1, coronal STIR, oblique
sagittal T1, and oblique sagittal STIR
• Optional sequences
Oblique sagittal and coronal contrast-enhanced fat-
saturated T1WI (for cases of known or suspected
neoplasm, scar, or infection)
Coronal technique with larger field of view (FOV) can
include contralateral BP for comparison
Imaging Pitfalls
• Too-large FOV reduces spatial resolution, compromises

visualization of internal BP architecture
• Technically simpler to evaluate supraclavicular plexus than
infraclavicular plexus
• STIR provides more reliable fat suppression than chemical
fat-saturated T2WI
• Motion artifact (especially respiratory motion of chest) can
degrade image quality
• Subclavian and axillary vessels (especially venous
structures) can demonstrate linear high signal on fast spin-
echo or inversion recovery sequences and can be difficult to
separate from BP
Saturation bands can help decrease vascular signal
• Enhancing vascular structures and normal perineural
venous plexus can mimic pathologically enhancing BP
components
Clinical Importance
• Variety of pathologies can affect BP, including idiopathic

inflammation, traumatic injuries, neoplasm, and
compression syndromes
• Due to complex anatomy of BP and variable pathologies,
clinical symptoms may range from focal neurologic
symptoms involving distal branch to more extensive
brachial plexopathy involving multiple nerves
• Combination of neurologic evaluation and MR is key to
identifying and localizing lesion as well as treatment
planning
Image Gallery
Print Images
GRAPHIC: OVERVIEW
Coronal graphic demonstrates an overview of the cervical
spine and supraclavicular brachial plexus. This shows the
basic arrangement of the cervical ventral primary rami
combining to form the brachial plexus. The C1-7 cervical
nerves exit above the same numbered pedicle, C8 nerve
exits above the T1 pedicle, and more caudal roots exit
below their numbered pedicle.
Coronal graphic of the brachial plexus demonstrates an
overview of the more distal plexus elements extending into
the axilla. The trunks recombine into posterior and anterior
divisions that form the cords. The posterior cord forms the
radial and axillary nerves. The medial cord forms the ulnar
nerve, while the lateral cord forms the musculocutaneous
nerve. The median nerve is formed from branches of both
the lateral and medial cords.
GRAPHIC: BRACHIAL PLEXUS

Graphic schematically demonstrates the components of the
brachial plexus. The exiting nerves quickly divide into small
dorsal rami and larger ventral rami. The ventral rami (roots)
of C5-T1 pass into the scalene triangle and merge into
trunks. The upper trunk is formed by C5 and C6 ventral rami
or roots. The middle trunk is formed by continuation of the
C7 root. The lower trunk is formed by the coalescence of
C8 and T1 roots. Each trunk divides into a ventral and
dorsal division. The 3 dorsal divisions merge into the
posterior cord. Ventral divisions of the upper and middle
trunks unite to form the lateral cord. The ventral division of
the lower trunk merges and forms the medial cord. The
cords ultimately give rise to the terminal branches of the
upper extremity.
CORONAL RELATIONSHIPS OF BRACHIAL PLEXUS
Graphic demonstrates the relationship of the proximal

brachial plexus to the vertebral bodies, middle scalene
muscle, subclavian artery, and pulmonary apex. The
anterior scalene has been removed to expose the scalene
triangle, the region between the scalene muscles. Note the
subclavian vein passes anterior to the inferior attachment of
the anterior scalene muscle and the subclavian artery
passes posterior to this attachment. The subclavian artery
can serve as a marker to find the brachial plexus elements
on imaging. Note that if an apical lung tumor invades
superiorly, it often involves the subclavian artery before it
involves the brachial plexus.
Slightly more anterior image demonstrates the proximal

cervical roots/ventral primary ramus (VPR) combining to
form the upper and middle trunks of the brachial plexus.
Normal nerve is slightly isointense to muscle on T1 MR
imaging. Note the close anatomic proximity of the brachial
plexus elements to the subclavian artery.
Image shows the proximal cervical ventral rami "roots"
combining to form the upper and middle trunks of the
brachial plexus. Normal nerve is slightly hyperintense to
muscle on STIR and FS T2 MR imaging.
AXIAL ANATOMY: PROXIMAL CERVICAL NERVES

Graphic demonstrates ventral & dorsal roots of C6 nerve
merging in upper medial neural foramen (NF). Localized
expansion of the dorsal nerve is the dorsal root ganglion
(DRG). Note the intimate relationship of the DRG to the
vertebral artery as it passes through NF. The extraforaminal
nerve descends slightly toward the lateral neural sulcus that
cradles the nerve before it extends into the scalene triangle.
When the nerve is within lateral neural sulcus, it is
separated from the vertebral artery within transverse
foramen by thin bony bridge of the lateral process.
Axial CTA images descending through C5-6 disc space
shows there is prominent enhancement of epidural &
perineural venous plexus that surround exiting nerves.
Axial images continue to descend from disc space at C5-6
into C6 vertebrae. As the nerve begins to exit NF, it moves
inferiorly & laterally & begins to separate from vertebral
artery. The extraforaminal nerve will pass lateral to the
transverse process within a shallow groove known as lateral
neural sulcus, which is a reliable landmark for cervical
nerves C3-6. In many patients, it is difficult to fully
distinguish separate scalene muscles on imaging.
CORONAL STIR MR
Coronal T1 MR shows vertebral bodies (upper) & anterior
scalene muscles (lower). Anterior scalene muscles arise
from transverse processes of the cervical vertebrae &
attach to the 1st rib laterally. Subclavian vein passes
anteriorly to attachment of anterior scalene.
Coronal T1 MR reveals the difficulty in distinguishing normal
nerve tissue from adjacent muscle. Oblique bands of
hypointense tissue traverse the ventral face of middle
scalene muscle, but the nerves are difficult to separate from
oblique tendinous attachments of the muscle itself. There is
minimal interscalene fat to provide satisfactory contrast.
Subclavian artery is a useful landmark for determining the
best plane for proximal components of the brachial plexus,
particularly the trunks. The trunks will pass above the
subclavian artery as it passes over the 1st rib.
Coronal STIR MR shows relative hyperintensity of normal
nerves to muscle. Fat has been suppressed to enhance
contrast resolution of nerves. Note DRGs are easily
identified as focal enlargements of proximal nerves within
NF. Given complex curvature of components, it is difficult to
obtain a full view of the brachial plexus in a single slice.
AXIAL STIR MR
First of 4 axial STIR MR images presented from rostral to
caudal shows the upper brachial plexus elements (C5-7
VPR) traveling between the anterior and middle scalene
muscles in preparation to form the brachial plexus.
Image at the C7/T1 level depicts the linear alignment of the
C5 through C8 VPR. C5 and C6 are closely approximated
and form the left upper trunk.
Imaging more caudal at C7/T1 level depicts the upper trunk
on the left. Note that the brachial plexus elements exit the
neck between the anterior and middle scalene muscles.
SAGITTAL OBLIQUE STIR MR

First of 4 sagittal oblique STIR MR images presented from
medial to lateral demonstrates the ventral primary rami of
C5 through T1 proximal to the trunks. C8 exits above the
1st rib while T1 exits below. The brachial plexus is normally
sandwiched between the anterior and middle scalene
muscles.
A slightly more lateral slice demonstrates the formation of
the upper, middle, and lower trunks arranged in a vertical
line between the scalene muscles. The C5 and C6 VPR can
still be resolved as distinct elements within the upper trunk
at this level.
SAGITTAL OBLIQUE STIR MR

Image at the division level shows mixing and matching of the
trunks into anterior and posterior divisions. Note that the
divisions are retroclavicular. The posterior divisions will form
the posterior cord, and the anterior divisions will form the
lateral and medial cords. It is generally not possible to
follow individual branches of the divisions from trunk to cord.
Image demonstrates the formation of the 3 cords (lateral,
medial, and posterior). The most important terminal branch
of the lateral cord is the musculocutaneous nerve. The
posterior cord forms the axillary and radial nerve terminal
branches. The medial cord terminates as the ulnar nerve.
ANATOMIC-PATHOLOGIC CORRELATION
Coronal FS T2 MR demonstrates mild relative
hyperintensity in the brachial plexus diffusely in the right side
of this patient with idiopathic plexitis.
Coronal STIR MR depicts massive enlargement of all
proximal cervical nerves and supraclavicular components of
the brachial plexus in this patient with neurofibromatosis
type 1. In this case, essentially all the nerves have given
rise to neurofibromas.
Axial T2 and FS contrast-enhanced T1 MR images through
the C4-5 NF demonstrate a solitary enlarged, fusiform
enhancing mass along the proximal C5 nerve on the
patient's left. Notice the lesion's relationship to the left
vertebral artery; the lesion pushes the vertebral artery
anteriorly. Notice the DRG on the unaffected side enhances
normally.
Lumbar Plexus
Main Text
T ERM INOLOGY
Abbreviations
• Lumbar plexus (LP)

• Lumbosacral plexus (LSP), lumbosacral trunk (LST)
GROSS ANATOMY
Overview
• LP
Formed by
– L2-L4 ventral rami
– Minor branches of L1, T12
2 major branches
– Femoral nerve (posterior divisions, L2-L4)
– Obturator nerve (anterior divisions, L2-L4)
Minor branches, constituent rami
– Iliohypogastric (L1)
– Ilioinguinal (L1)
– Genitofemoral (L1, L2)
– Lateral femoral cutaneous (L2, L3)
– Superior gluteal nerves (L4-S1)
• LST
Formed by
– L5
– L4 ventral rami (minor branch)
• LSP
Formed by
– LST (L5, minor branch of L4)
– S1-S4
• LP
Lies in posterior aspect of psoas major
Anterior to lumbar vertebral transverse processes
Courses medial to psoas, ventral to quadratus lumborum
• Femoral nerve
Largest and major terminal branch of LP
Arises from L2-L4
Courses inferiorly, medial to psoas major
Emerges between psoas, iliacus
Passes behind inguinal ligament into thigh
Splits into anterior, posterior divisions
Sensory, motor fibers mixed in peripheral nerves
Femoral artery lies medial to nerve
IMAGING ANATOMY
Overview
• General concepts
Perineural fat surrounds, provides excellent visualization
of LP
Normal nerve fascicles are uniform size, shape
• MR
Intrafascicular signal intensity determined by
– Endoneurial fluid
– Axoplasmic water
Interfascicular signal intensity
– Fibrofatty connective tissue
– Susceptible to fat suppression

Questions
• MR
T1WI + fat-saturated T2WI/STIR sequences
complementary
T1WI
– Normal LP is well-defined ovoid structure
– Discrete fascicles isointense to adjacent muscle
Fat-saturated T2WI/STIR
– LP slightly hyperintense to adjacent muscle
– Hypointense to regional vessels
– Discrete fascicles clearly defined, separated by lower
intensity connective tissue
• Coils
Surface coil preferred (body or cardiac depending on
patient size)Specific Terms
Spine phase array coil alternative
– Provides inferior signal to noise ratio (SNR)
– Especially notable in lateral aspects of posterior
abdomen, pelvis
Body coil
– Good spatial coverage
– Poor SNR severely limits utility
• Planes
Coronal, oblique sagittal
From L3 superiorly through ischial tuberosity inferiorly
From spine medially through greater trochanter laterally
• Sequences
Coronal T1WI
Coronal STIR or fat-saturated T2WI
Direct axial or oblique axial T1WI
Direct axial or oblique axial fat-saturated T2WI/STIR
Optional: T1 C+ (if known/suspected neoplasm, scar,
infection)
• Specific recommendations
For neural foramina, proximal L4-L5 ventral rami, LST,
sciatic nerve: Direct coronal, axial planes preferred
For optimal visualization of LP internal architecture:
Oblique axial plane preferred
Imaging Pitfalls
• Nerves, vessels may be difficult to differentiate

Nerves
– Round/ovoid linear structures
– No flow voids
– Branch at relatively acute angles
– Enhance minimally
– Show distinctive "fascicular" architecture (on axial)
Vessels
– Round/ovoid, linear
– Have internal flow voids
– Branch at large angles
– Enhance intensely
• Normal peripheral nerves, lesions (e.g., schwannoma) both
have high T2 signal
Nerves have distinct fascicular pattern
Masses obscure or displace fascicles
Image Gallery
Print Images
GRAPHICS
Coronal graphic shows the lumbosacral spine, pelvis,

coccyx, and nerves. The lumbar plexus is composed of
ventral primary rami of L2-L4. The plexus splits into a larger
posterior division, which forms the femoral nerve and a
smaller anterior division that forms the obturator nerve.
Coronal graphic demonstrates the relationship of plexi to
pelvic musculature and soft tissues. The lumbar plexus runs
ventral to the quadratus lumborum and iliacus muscles and
medial to the psoas muscle. The femoral nerve, the major
terminal branch of the lumbar plexus, travels in the groove
between the iliacus and psoas muscles and passes under
the inguinal ligament to exit the pelvis at the femoral canal.
The femoral artery and vein lie medial to the femoral nerve.
CORONAL T1 MR
First of 3 coronal T1 MR images presented from anterior to
posterior is shown. This image demonstrates the lumbar
plexus and ipsilateral femoral nerve traveling along the
medial aspect of the psoas muscle.
This image demonstrates the normal lumbar plexus arising
from its primary neural input (L2-L4). Normal nerve is
isointense to normal muscle. The lumbar plexus is easily
identified by locating the medial border of the psoas muscle.
Image more posteriorly shows the normal proximal L3, L4,
and L5 roots and rami exiting under the vertebral pedicle.
L3 and L4 will join L2 to form the lumbar plexus and
subsequently divide into anterior and posterior divisions,
respectively, to form the obturator and femoral nerves. L5
will join a minor branch of L4 to form the lumbosacral trunk,
a primary component of the sacral plexus.
CORONAL T2 FS MR
First of 3 coronal T2 FS MR images presented from
anterior to posterior is shown. This image demonstrates the
lumbar plexus and its component L2-L4 roots/rami. Also
seen is the proximal femoral nerve transiting along the
medial ipsilateral psoas muscle into the iliopsoas groove.
Normal nerve is mildly hyperintense to muscle on FS T2 or
STIR MR imaging.
This image better demonstrates the L4 contribution to the
lumbar plexus as well as the proximal lumbosacral trunk,
which will contribute to the sacral plexus.
More posterior image shows the proximal L3 and L4 roots
and rami exiting under the vertebral pedicles to form the
lumbar plexus along the medial psoas border.
AXIAL T1 MR
First of 2 axial T1 MR images presented from superior to
inferior is shown. This image depicts the lumbar plexus
(composed of L2 and L3 at this level) traveling adjacent to
the medial psoas muscle. A faint fascicular architecture is
apparent. Surrounding bright fat helps identification of the
plexus.
More caudal image shows the femoral nerve along the
medial psoas muscle. It is hard to identify the femoral nerve
at this level on T1 MR imaging because of its isointensity to
the muscle. L4 has joined the remainder of the lumbar
plexus at this level, and contributes to both the LP and the
lumbosacral trunk.
AXIAL T2 FS MR
First of 2 axial T2 FS MR images presented from superior
to inferior is shown. This image demonstrates the lumbar
plexus in its normal location medial to the ipsilateral psoas
muscle. At this level it is composed of L2 and L3, with the
L4 contribution joining caudal to this slice.
Imaging more inferiorly demonstrates the more caudal
lumbar plexus after the L4 contribution. The femoral nerve
has branched off and is tracking in the iliopsoas groove in
expected location.
Sacral Plexus and Sciatic Nerve
Main Text
T ERM INOLOGY
Abbreviations
• Lumbosacral trunk (LST), lumbosacral plexus (LSP)

• Sacroiliac (SI), sciatic nerve (SN)
GROSS ANATOMY
Overview
• LST
Formed by L4 (minor branch), L5
Nerve supply to pelvis, lower limb; autonomic to pelvic
viscera
Lumbar part
– Appears at medial margin of psoas major
– Courses inferiorly over pelvic rim anterior to SI joint
– Joins S1
Sacral part
– S2-S3 converge on LST in greater sciatic foramen →
SN
• Sacral plexus
Formed by
– LST
– Ventral rami, S1-S3
– Minor branch of S4
2 "bands"
– Upper band: LST (L4, L5) + S1-S3 → SN
– Lower band: S2-S4 → pudendal nerve
• SN
Major branch of sacral plexus
Coalesces from sacral plexus on ventral piriformis muscle
surface
Innervates
– Capsule of hip joint
– Posterior thigh (biceps femoris, semitendinosus,
semimembranosus, adductor magnus)
– All leg muscles (via common peroneal, tibial nerves)
• Pudendal nerve
Formed by S2-S4 ventral rami
Exits pelvis via greater sciatic foramen between
piriformis/ischiococcygeus
Innervates
– Inferior rectal nerve
– Perineal nerve
– Penis or clitoris
• Coccygeal plexus
Formed by
– Minor branch of S4 (forms anococcygeal nerve)
– S5 ventral rami
– Coccygeal ventral rami
• Sacral plexus
Lies against posterior pelvic wall, behind presacral fascia
– Anterior to piriformis
– Posterior to ureter
– Posterior to internal iliac vessels
– Behind sigmoid colon
Iliolumbar artery accompanies L5 nerve
Lateral sacral artery branches accompany sacral nerves
Superior gluteal artery passes backward between L5/S1
nerves
Inferior gluteal vessels lie between S1/S2 or S2/S3
• SN
Thickest nerve in body
Exits pelvis
– Via greater sciatic foramen
– Below piriformis muscle
Descends between greater trochanter of femur, ischial
tuberosity
Descends along posterior thigh
Divides (usually near apex of popliteal fossa) into 2
branches
– Tibial nerve
– Common peroneal nerves
• Pudendal nerve
Courses through greater sciatic foramen between
piriformis, ischiococcygeus
Lies medial to internal pudendal vessels on spine
Accompanies internal pudendal artery through lesser
sciatic foramen into pudendal canal

Imaging Approaches
• SN
Coils
– Body or cardiac surface coil preferred (smaller
coverage, better SNR)
– Flexible extremity surface coil alternative (more
coverage, less SNR)
Planes: Coronal, oblique, and direct axial
Sequences
– Coronal T1WI, coronal STIR or fat-saturated T2WI
– Direct axial or oblique axial T1WI
– Direct axial or oblique axial fat-saturated T2WI or
STIR
– Optional: Coronal/direct or oblique axial fat-
saturated T1 C+
Clinical Importance
• Compression syndromes
Piriformis
– Sciatic neuropathy
– Trapped/irritated at piriformis muscle (controversial)
Ischial tunnel
– Sciatic neuropathy
– Compressed between obturator internus/gluteus
maximus
– At level of ischium
Sacral plexus
– Dense presacral fascia protects sacral plexus
– Sacral plexus rarely directly involved in malignant
pelvic tumors
– Sacral plexus can be compressed indirectly
• LSP and SN easily visualized on imaging; normal pudendal
nerve usually too small to identify as discreet structure
Image Gallery
Print Images
GRAPHICS
Coronal graphic depicts the upper and lower sacral bands
of the sacral plexus. The primary terminal branch of the
upper sacral band is the sciatic nerve, which supplies many
thigh muscles and all leg muscles (via the tibial and common
peroneal nerves). The lower sacral band forms the
pudendal nerve to the perineum.
Sagittal graphic depicts the upper and lower bands of the
sacral plexus in anatomic relationship to musculature of the
pelvic bowl. The upper sacral bands coalesce into the
sciatic nerve on the ventral surface of the piriformis muscle.
CORONAL T1 MR
First of 2 coronal T1 MR images through the pelvis is
presented from posterior to anterior. This image
demonstrates the S2 nerve contributing to the sacral plexus
and sciatic nerve.
Image obtained more anterior in the pelvis demonstrates
the sacral plexus coalescing into the sciatic nerve on the
ventral surface of the piriformis muscle.
OBLIQUE AXIAL T1 MR AND FS T2 MR

The sciatic nerve coalesces from the sacral plexus on the
ventral surface of the piriformis muscle. On T1 MR images,
the fascicles are isointense to muscle separated by bright
fibrofatty connective tissue. The fascicular architecture
permits ready distinction from vessels.
The sciatic nerve coalesces from the sacral plexus on the
ventral surface of the piriformis muscle. On FS T2 MR
images, the fascicles are mildly hyperintense to muscle
separated by dark (fat-suppressed) fibrofatty connective
tissue. The fascicular architecture permits ready distinction
from vessels.
Oblique axial T1 MR shows the sciatic nerve on the ventral
piriformis muscle. Although the nerve (largest single nerve in
the body) is enveloped by epineurium, the abundant
fibrofatty epineurium gives the impression that the individual
fascicles are free in pelvic fat.
The sciatic nerve is a more discrete structure on fat-
saturated T2 or STIR MR images, with distinctive mildly
hyperintense fascicles separated by interspersed dark (fat-
suppressed) fibrofatty connective tissue.
AXIAL T1 MR AND FS T2 MR
Axial T1 MR of the sciatic nerve at the obturator internus
level is readily identified between the obturator internus and
gluteus maximus muscles. The normal sciatic nerve is
smaller and flatter-appearing at this level than at the
piriformis level.
Axial T2 MR of the sciatic nerve at the obturator internus
level is readily identified between the obturator internus and
gluteus maximus muscles. The normal fascicular
architecture is distinctive and permits discrimination from
adjacent veins.
Peripheral Nerve and Plexus
Overview
Main Text
T ERM INOLOGY
Abbreviations
• Peripheral nervous system (PNS)

• Dorsal root ganglion (DRG)
GROSS ANATOMY
General Concepts
• Ramus
1st branch(es) of spinal nerve proper
– Ventral primary ramus (VPR) (larger branch) →
ventral musculature, facet
– Dorsal primary ramus (DPR) (smaller branch) →
paraspinal muscles, facet
• Nerve
4-10 or more fascicles surrounded by epineurium
• Fascicle
Nerve fibers (hundreds) surrounded by connective tissue
• Connective tissue (covers nerve fibers)
Epineurium
– Outer layer of connective tissue
– Longitudinally oriented
– Continuous with surrounding connective tissues
– Groups fascicles into nerves, limits stretching
Perineurium
– Intermediate layer of connective tissue
– Multilayered sheath that invest fascicles
– Extends from nerve roots to nerve ends
– Functions as blood-nerve barrier
Endoneurium
– Innermost layer of connective tissue
– Intrafascicular, surrounds individual nerve fibers
• Peripheral nerve
Combination of 1 or more rami
± Schwann cell myelin sheath
Sensory, motor fibers usually mixed
– Some PNS branches purely sensory
• Plexus
Network of anastomosing nerves
Overview
• Brachial plexus
Composed of C5-T1 VPRs ± minor C4, T2
Major branches
– Radial nerve
– Median nerve
– Ulnar nerve
– Musculocutaneous nerve
– Axillary nerve
• Lumbar plexus
Composed of
– L2-4 VPRs
– Minor T12, L1 branches
Major branches
– Obturator nerve
– Femoral nerve
• Lumbosacral trunk (LST)
Composed of
– L5 + L4 VPR (minor)
Functionally part of sacral plexus
• Sacral plexus
Composed of
– LST + S1-3 VPRs
– Minor branch of S4
Major branches
– Sciatic nerve
– Common peroneal nerve
– Tibial nerve
• Nerves usually accompanied by similarly named arteries,

veins
Supply similar target tissues
Form "neurovascular bundle"
IMAGING ANATOMY
Normal
• MR findings
Nerves appear round/ovoid
Well-defined internal fascicular architecture
No abrupt change in caliber, course
STIR/fat-suppressed T2WI
– Fascicles appear mildly hyperintense
– Interspersed with hypointense fibrofatty connective
tissue
Abnormal
• Abnormal size (usually enlarged)

• ± loss of normal fascicular architecture
• Abrupt change in caliber or course
• Intrinsic mass
• STIR/fat-suppressed T2WI
Hyperintense; approach signal of vessels
• High-resolution MR
T1WI MR (relationship to adjacent structures)
STIR/fat-suppressed T2WI (fascicular anatomy)
Fat-saturated T1 C+ (neuritis vs. tumor, etc.)
Imaging Pitfalls
• Nerves, vessels sometimes difficult to differentiate

Nerves
– Round/ovoid, linear
– No flow void
– Branch at relatively acute angles
– Enhance minimally
– Distinctive axial fascicular architecture
Vessels
– Also round/ovoid, linear
– Have internal flow voids
– Branch at large angles
– Enhance intensely
Clinical Importance
• Neuropathy syndromes specific to abnormal nerve(s)
• Imaging complimentary to clinical exam, electrodiagnostic
testing
Image Gallery
Print Images
GRAPHICS
Overview graphic of the lower cervical and upper thoracic

spinal nerves as seen from the front shows the general
pattern of how ventral primary rami (VPRs) form plexi and
peripheral nerves. The upper 4 cervical ventral rami form a
cervical plexus; the lower 4 plus contributions from the 1st
thoracic ventral ramus form the brachial plexus (shown on
the left). The VPRs form trunks, which then form divisions
and cords. Peripheral nerves arise from the trunks to supply
the shoulder and upper limb (shown on the right).
Close-up axial graphic shows how a typical spinal nerve is

formed and then gives rise to ventral and dorsal primary
rami. A lower thoracic vertebral segment is depicted. The
ventral branch supplies ventral musculature while the dorsal
branch is smaller and supplies paraspinal muscles.
Graphic depicts formation of a prominent peripheral nerve

to the arm, the median nerve. The median nerve arises from
branches of both the lateral and medial brachial plexus
cords and passes directly through the arm [median nerve
has no branches in the axilla or arm and serves no brachial
(arm) muscles]. At the elbow, the median nerve gives off
the anterior interosseous nerve branch and continues as the
median nerve proper into the hand under the flexor
retinaculum.
Graphic cutaway of a typical peripheral nerve illustrates the

characteristic internal architecture that permits imaging
distinction from vessels. Each axon has a connective tissue
covering called the endoneurium. Axons are bundled
together to form fascicles that are bounded externally by
the perineurium. Fascicles are bundled together to form a
peripheral nerve, surrounded by the tough epineurium. This
general pattern is followed for all peripheral nerves of both
extremities and the trunk.
CORONAL T1 AND STIR MR
Coronal T1 MR of the right brachial plexus and its roots

shows the normal longitudinal T1 appearance of peripheral
nerves. Peripheral nerves are isointense to normal muscle
on T1 MR images.
Coronal STIR MR of the right brachial plexus shows the
normal longitudinal T2 appearance of peripheral nerves.
Peripheral nerves are mildly hyperintense to normal muscle
on fat-saturated T2 or STIR MR images. Note that the
fascicular architecture is not always apparent on longitudinal
imaging.
AXIAL T1 AND T2 FS MR
Direct axial T1 MR of the sciatic nerve is coned and
magnified to show the characteristic transverse fascicular
appearance of peripheral nerves. The sciatic nerve is the
largest single nerve in the body and is well suited for
learning to recognize normal nerve internal architecture. The
nerve fascicles are isointense to muscle and are surrounded
by higher signal intensity fibrofatty tissue. As in this
instance, peripheral nerves are frequently marginated by
bright fat, which assists delineation from surrounding soft
tissues.
Axial FS T2 MR of the left sciatic nerve reveals the normal
T2 appearance of the peripheral nerve. The individual
fascicles are distinct and slightly hyperintense to adjacent
muscle. Low-signal fibrofatty connective tissue (fat is
suppressed by fat-saturation or STIR MR imaging)
accentuates conspicuity of the individual fascicles.
INDEX
A
Abducens division of CNV (CNVI), 382
Abducens nerve (CNVI), 113, , 114, , 115, , 120, , 303, , 305, , 319, , 320, , 322, , 329, , 387, , 407, , 409, ,
422, , 423, , 424, , 425, , 429, , 466, , 469, , 472, , 473, , 480–483, , 497, , 608
3T axial T2 & T1 C+ MR, 482
within cavernous sinus sinusoids, 119
cisternal, 424, , 485
in Dorello canal, 470
exiting cavernous sinus, through superior orbital fissure, 113
fibers, 319
graphics, 481
location, 382
nuclei, 318, , 319
3T sagittal T2 MR, 483
Abducens nucleus, 480, , 481
Aberrant right subclavian artery, 531
Accessory atlantoaxial ligament, 711
Accessory attentional regions, 268
Accessory inferior temporal and occipital language regions, 290
Accessory meningeal artery, 551
Accessory nerve (CNXI), 303, , 361, , 413, , 422, , 503, , 504, , 509, , 511, , 514, , 516–519, , 521
ascending portion, 413
bulbar portion of, 519
dysfunction, 516
graphics
axial bone CT and 3T T2 MR, 519
intracranial and extracranial, 518
nuclei, 326
in pars vascularis, 521
spinal, 423, , 425
spinal portion of, 519
spinal root, 328, , 428
Acetylcholine, 260
Acute symptoms, primary motor cortex, 134
Addiction
anterior cingulate cortex, 200
dorsolateral prefrontal cortex, 158
insula and parainsula areas, 176
orbitofrontal cortex, 170
Adenohypophysis (AH). See also Cavernous sinus; Pituitary gland; Sella.
anterior lobe, pituitary gland, 123
Adenoids, 406
ADHD, primary motor cortex, 134
Adventitia, 542
Agenesis of corpus callosum, 77
Aging, substantia innominata, 95
Alar ligament, 689, , 711, , 724, , 726
Alisphenoid, 402
Alveus, 41, , 101, , 102, , 103, , 106, , 108
of hippocampus, 102
Alzheimer dementia
parahippocampal gyrus, 218
posterior cingulate cortex, 194
retrosplenial cingulate cortex, 212
Alzheimer disease, superior prefrontal cortex, 152
Ambient cistern, 101, , 102, , 104, , 105, , 107, , 306, , 314, , 316, , 317, , 364, , 460
basal vein of Rosenthal, 363
posterior cerebral artery, 350
Ambient (perimesencephalic) cisterns, 358
Ambient (P2) posterior cerebral artery segment, 576, , 577, , 578, , 579, , 580, , 581, , 584, , 585
Ammon horn of hippocampus, 100, , 102
Amygdala, 33, , 36, , 40, , 79, , 84, , 98, , 100, , 104, , 106, , 108, , 109, , 110, , 176, , 206, , 225, , 230, ,
262, , 263, , 288, , 294, , 297, , 298, , 299, , 435
temporal cortex, 92
Amygdalohypothalamic connections, 206
Amyotrophic lateral sclerosis, primary motor cortex, 134
Angular and supramarginal gyri, 293
Angular artery, 568, , 570, , 572
with angiographic “sylvian point, ”, 571
with “sylvian point, ”, 572, , 575
Angular gyrus (area 39), 30, , 34, , 35, , 45, , 158, , 190, , 210, , 233, , 234
Angular gyrus syndrome, inferior parietal lobule, 236
Annulus fibrosus, 679, , 691, , 693, , 694, , 696, , 702, , 762
with lamellar structure, 697
Annulus fibrosus complex, 690, , 691, , 692, , 694
Annulus of Zinn, 459
Annulus tendineus (annulus of Zinn), 441, , 452
Ansa cervicalis, 520, , 522
Anterior and lateral thalamic nuclei, 212
Anterior and mid insula, 204
Anterior arch, 663, , 666, , 712
Anterior articular facet, median atlantoaxial joint, 713
Anterior atlantoaxial joint, 742
Anterior atlantodental joint, 720, , 722, , 724, , 725
Anterior atlantooccipital membrane, 710, , 711, , 724, , 725
Anterior belly digastric muscle, 467
Anterior branch, middle meningeal artery, 540
Anterior carotid sulcus, 376
Anterior caudate vein, 601, , 604, , 614, , 624, , 625, , 626, , 627
Anterior (petrosal) cerebellar fissures, 330. See also Cerebellum.
Anterior cerebral artery (ACA), 80, , 120, , 355, , 362, , 446, , 457, , 546, , 547, , 549, , 556, , 558, , 562–
567, , 600. See also Intracranial arteries.
3T MRA, 566
A1 segments, 367
AP DSA, 565
CTA, 567
embryology, 562
graphics, 563
interhemispheric fissure, 355, , 363, , 367
lateral DSA, 564
pericallosal branch, 583
Anterior cerebral artery ischemia, frontal pole, 164
Anterior cerebral vein, 617
Anterior choroidal artery (AChoA), 549, , 551, , 552, , 553, , 554, , 555, , 561, , 571. See also Intracranial
arteries.
Anterior cingulate, 180, , 298
Anterior cingulate cortex (areas 24, 32, 33), 43, , 45, , 152, , 159, , 161, , 176, , 182, , 200–205, , 270, ,
272, , 273
associated disorders, 200
coactivation, 202
connectivity to
bilateral Brodmann area, 24, 204
left, 203
Anterior circulation, 546
Anterior clinoid process (lesser sphenoid wing), 6, , 116, , 120, , 373, , 375, , 382, , 383, , 384, , 386, ,
387, , 389, , 392, , 443, , 446, , 471, , 473, , 556, , 557, , 608
Anterior commissure, 21, , 22, , 25, , 50, , 57, , 58, , 75, , 79, , 82, , 84, , 86, , 88, , 96, , 98, , 99, , 104, ,
106, , 110, , 122, , 315, , 347, , 350, , 354, , 357, , 363, , 365, , 368, , 443
brain, 30, , 34, , 36
fibers crossing, 435
Anterior communicating artery (ACoA), 118, , 547, , 558, , 559, , 560, , 563, , 566. See also Intracranial
arteries.
hypoplastic, 567
Anterior cortical margin, 756, , 757
Anterior cranial fossa, 6, , 375
floor, 438
Anterior cribriform plate, 438
Anterior deep temporal artery, 540
Anterior dural margin, 694
Anterior epidural space, 685
epidural veins, 691
Anterior ethmoid air cells, 389, , 390, , 391, , 394, , 395
Anterior ethmoid artery canal, 376
Anterior ethmoid artery foramen, 376
Anterior ethmoid nerves, 467
Anterior ethmoid sinus, 378, , 381, , 397, , 436
Anterior ethmoidal artery, 384–385, , 387
Anterior ethmoidal canal, 384–385, , 387
Anterior ethmoidal foramen, 384–385, , 390
medial, 386
Anterior ethmoidal sulcus, 384–385
Anterior genu, cavernous (C4) internal carotid artery, 537, , 551, , 552, , 553, , 554, , 555, , 557
Anterior hippocampus, 84, , 88
Anterior inferior cerebellar artery (AICA), 320, , 322, , 328, , 329, , 332, , 342, , 343, , 429, , 461, , 507, ,
513, , 547, , 549, , 586, , 594. See also Intracranial arteries.
left, 593
loop, 338, , 342, , 429
looping into internal auditory canal, 593
prepontine cistern, 365
right, 588, , 593
Anterior inferior insula, 178
greatest connectivity to, 179
Anterior insula (area 13), 146, , 158, , 203, , 270, , 271, , 273, , 298, , 299
Anterior insular cortex, 159
Anterior intercavernous sinus, 116
Anterior internal frontal arteries, 562
Anterior internal vertebral venous plexus, 746
Anterior interosseous nerve, 858
Anterior jugular vein, 643, , 644, , 651
Anterior limb, internal capsule, 31, , 34, , 40, , 56, , 57, , 59, , 61, , 62, , 63, , 64, , 65, , 66, , 67, , 68, , 69, ,
70, , 71, , 72, , 73, , 74, , 75, , 80, , 81, , 82, , 83, , 86, , 87, , 90, , 91, , 96
Anterior longitudinal ligament, 654, , 678, , 679, , 684, , 689, , 690, , 691, , 692, , 693, , 694, , 695, , 697, ,
711, , 725, , 757, , 759, , 762, , 768, , 769
complex, 702
Anterior margin foramen magnum (basion), 723
Anterior median atlantoaxial joint, 711
Anterior median fissure, 320
of spinal cord, 746
Anterior median sulcus of spinal cord, 738
Anterior medullary segment, posterior inferior cerebellar artery, 588, , 592, , 593, , 594
Anterior (superior) medullary velum, 347, , 350
Anterior medullary venous plexus, 637
Anterior/midcingulate, 271
Anterior neuropore, 388, , 394
Anterior nuclear group, 92
Anterior parietal (postcentral sulcus) artery, 570
Anterior perforated substance, 98, , 99, , 435
Anterior pontomesencephalic vein/venous plexus, 603, , 632, , 636, , 637, , 638, , 641
Anterior precuneus, 194
Anterior (ventral) ramus, 857
Anterior sacral promontory, 785
Anterior scalene muscle, 837, , 839, , 840, , 841
Anterior skull base (ASB), 372, , 384–399, , 401
3T coronal T2 MR development, 396–397
3T sagittal T1 MR development, 398
3T sagittal T2 MR development, 399
axial CT, 389–391
development, 394
bones forming, 384
bony landmarks, 384
boundaries, 384
coronal CT, 392–393
development, 395
development, 385
foramina and fissures, 384–385
graphics, 386–388
relationships, 384
Anterior spinal arteries (ASAs), 586, , 588, , 802, , 812, , 814, , 817, , 819, , 820, , 821, , 838
Anterior spinal branch, 591
Anterior superior insula, 178
Anterior (petrosal) surface, 336
Anterior temporal artery, 569, , 570, , 571, , 572, , 577, , 578, , 579, , 584
branches, 570, , 571
Anterior temporal pole, 298
Anterior thalamic radiation, 55, , 56, , 57
Anterior thalamoperforating arteries, 561, , 578, , 592
Anterior tubercle, 729
Anterior tubercle transverse process, 736, , 737, , 743, , 745, , 747
Anterior tympanic segment, facial nerve, 486, , 489, , 496
Anterior vertebral line, 728, , 732
Anteroinferior cerebellar artery, 497, , 498
Anxiety conditions, insula and parainsula areas, 176
Aorta, 702, , 754, , 755, , 759, , 769, , 770, , 771, , 774, , 775, , 817, , 818
flash filling, 819
Aortic arch (AA), 530–533, , 829. See also Cervical carotid arteries.
3D-VRT CECT, 533
graphics, 531
left anterior oblique DSA, 532
normal variants, anomalies, 530
Aortic bifurcation, 769, , 774
Apex of falx cerebri, 15
Apex of tentorium cerebelli, 13
Apical ligament, 711, , 725
Apophyseal joint. See Facet joints.
Arachnoid, 10, , 12, , 18, , 19, , 20, , 113, , 114, , 360, , 608, , 617, , 801, , 802
granulation, 13, , 609, , 610
Arachnoid cyst, 308, , 321
Arachnoid mater, 802
Arcuate eminence, 488, , 489
Arcuate fasciculus
anterior segment, 293
posterior segment, 293
white matter pathway, 291
Arcuate fasciculus homologue white matter pathway, 268
Arteria thyroidea ima, 532
Arterial inflow distribution, 289
Artery of Adamkiewicz, 813, , 819, , 821
Artery of foramen rotundum, 535, , 551
Articular facet, for dens, 712
Articular pillar, 729, , 731, , 734, , 737, , 744, , 745, , 747
Articular processes, 696, , 728
Ascending aorta, 813
Ascending cervical artery, 532, , 820
thyrocervical trunk, 532
Ascending cervical branch, thyrocervical trunk, 531
Ascending cervical vertebral artery segment, 533
Ascending pharyngeal artery, 534, , 535, , 536, , 537, , 539
Ascending thoracic aorta, 531
Association cortical regions, 131
Association fibers, 50
brain, 28
Asymmetric petrous apices, 412
Atlantoaxial joint, 689, , 718, , 719, , 721, , 722, , 723, , 724, , 726, , 727, , 735, , 738, , 739, , 740
Atlantodental interval (ADI), 710, , 717
Atlantooccipital articulation, 589
Atlantooccipital joints, 418, , 421, , 699, , 703, , 710, , 711, , 718, , 719, , 720, , 722, , 723, , 724, , 726, ,
738, , 739, , 740
angle, 710, , 714
Atlas (C1) lateral mass, 524, , 525
Atrial veins, 624
Atrium, 346, , 347
Attention control network, 256, , 268–273
attentional subnetworks, 272
cognitive space, topographic maps, 271
regions
core, 270
laterality, 273
Auditory attention, 271
Auditory cortex, 130, , 137, , 180, , 244, , 278, , 290, , 292
Auditory processing, 188
Auricular branch (Arnold nerve), vagus nerve, 508
Auriculotemporal nerve, 467
Autism
fusiform gyrus, 224–229
superior prefrontal cortex, 152
Autonomic perception, anterior cingulate cortex, 200
Axillary artery, 833, , 837
Axillary nerve, 835, , 836
Axon, 859
B
Ballism, subthalamus, 78
Basal forebrain, 94, , 99, , 230
Basal ganglia (BG), 28, , 78–93, , 146, , 158, , 176, , 274, , 289, , 290, , 294
axial CECT, 81
3T axial T1 MR, 82–83
connectivity, 93
3T coronal T1 MR, 84–85
7T coronal T2-TSE MR, 88–89
graphics, 79–80
input and output, 92
7T postmortem axial T1 MR, 90–91
vascular supply, 78
Basal turn of cochlea, 496, , 499
Basal vein, 445, , 461
Basal vein of Rosenthal (BVR), 125, , 126, , 582, , 585, , 598, , 599, , 600, , 603, , 604, , 607, , 609, , 610, ,
613, , 616, , 619, , 620, , 621, , 623, , 624, , 625, , 627, , 628, , 629, , 630, , 631, , 632, , 634, , 637, , 826
deep middle cerebral vein to, 599
left, 617
right, 617
Base of brain, 28
Basilar artery (BA), 97, , 114, , 115, , 116, , 121, , 303, , 304, , 305, , 306, , 307, , 308, , 310, , 314, , 320, ,
321, , 322, , 323, , 325, , 329, , 332, , 362, , 428, , 429, , 445, , 453, , 455, , 461, , 466, , 469, , 513, , 546,
, 558, , 559, , 561, , 567, , 576, , 583, , 586, , 588, , 590, , 592, , 595, , 821. See also Cervical carotid
arteries; Intracranial arteries.
distal, 595
with pontine perforating arteries, 588
prepontine cistern, 349, , 362, , 364, , 365, , 368
trunk, 815
Basilar artery bifurcation, 559, , 594
Basilar artery in prepontine cistern, 359
Basilar perforating arteries, 592
Basilar plexus, 116
Basilar tip, 325
Basilar tip aneurysm, 573, , 590
Basilar venous plexus, 482
Basiocciput, 380, , 398, , 399, , 402, , 410, , 411, , 417, , 419, , 421, , 669
Basion, 711, , 718, , 719, , 723, , 724, , 725, , 739, , 740
Basisphenoid, 118, , 119, , 376, , 380, , 402, , 410, , 411, , 669
Basivertebral vein, 677, , 679, , 684, , 685, , 690, , 697, , 702, , 737, , 738, , 743, , 751, , 755, , 756, , 757, ,
766, , 767, , 768, , 772, , 773, , 818, , 822, , 823, , 829
Basivertebral venous plexus, 676
Bilateral area, 36, connectivity to, 220
Bilateral Brodmann area, 24, connectivity to, 204
Bilateral Brodmann area, 32, connectivity to, 205
Bilateral dorsolateral prefrontal cortex, connectivity to, 162
Bilateral frontal pole, connectivity, 168
Bilateral orbitofrontal cortex, connectivity to, 174
Bilateral orbitofrontal injury, orbitofrontal cortex, 170
Bill bar, 494, , 495
Biventral lobule, 331
Blood vessel, 103
Body
of caudate nucleus, 83, , 85, , 87, , 89
of corpus callosum, 36, , 37, , 39, , 41, , 83, , 88, , 89
Body of fornix, 41, , 75, , 101, , 104, , 106, , 110
Body of hippocampus, 105
Bones, 654
Bony eustachian tube, 405
Brachial plexus (BP), 511, , 657, , 832–843
anatomic-pathologic correlation, 843
axial stir MR, 840
branches, 833, , 836
clinical implications, 833
cords, 832, , 835, , 836, , 842
coronal relationships, 837
coronal stir MR, 839
divisions, 832, , 836, , 842, , 843
proximal cervical nerves, 838
roots, 832, , 836
sagittal oblique stir MR, 841, , 842
trunks, 832, , 835, , 836, , 837, , 841
Brachial plexus roots, 860
Brachiocephalic trunk (BCT), 530, , 531, , 532, , 533. See also Aortic arch; Cervical carotid arteries; Great
vessels.
Brachiocephalic vein, 643, , 644
Brachium conjunctivum, 330
Brachium pontis, 330, , 469, , 498
Brain: CSF spaces
subarachnoid spaces/cisterns, 358–369
ventricles and choroid plexus, 346–357
Brain: infratentorial brain
brainstem and cerebellum overview, 302–311
cerebellopontine angle/IAC, 338–343
cerebellum, 330–337
medulla, 326–329
midbrain, 312–317
pons, 318–325
Brain, skull base and cranial nerves
abducens nerve, 480
anterior skull base, 384–399
central skull base, 400–411
cranial nerves overview, 422–433
facial nerve, 484–493
oculomotor nerve, 450–457
olfactory nerve, 434–439
optic nerve, 440–449
posterior skull base, 412–421
skull base overview, 372–383
trigeminal nerve, 464–479
trochlear nerve, 458–463
Brain network anatomy
attention control network, 268–273
default mode network, 264–267
functional network overview, 256–259
language network, 290–293
limbic network, 288–289
memory network, 294–297
neurotransmitter systems, 260–263
sensorimotor network, 274–279
social network, 298–299
visual network, 280–287
Brainstem, 448, , 515, , 526. See also Deep gray nuclei.
7T axial T1 MP-RAGE, 307–308
7T axial T2 MR, 306
7T axial T2-SPACE MR, 304–305
graphics, 303
overview, 302–311
7T sagittal T2-SPACE MR, 311
Brainstem/posterior fossa veins, 598
Bregma, 4, , 7, , 8, , 9
Broca aphasia, 290
inferior frontal gyrus, 248
Broca area, 54, , 290, , 292, , 293
Broca homologue, 292
Brodmann area, 5, 144
left, connectivity to, 166
right, connectivity to, 167
Brodmann area 17/18, 186, , 187
Brodmann area, 19, 186, , 187
Brodmann area 20, 21, and 22, 192
bilateral, connectivity to, 204
Brodmann area 26, 217
Brodmann area 29 and 30, 217
Bulbar portion CNXI, 513
Bulbopontine sulcus, 483
C
C1 (atlas), 657, , 659, , 662, , 678, , 710
anterior arch, 419, , 689, , 702, , 711, , 712, , 718, , 720, , 722, , 724, , 725, , 727, , 730, , 735, , 739, ,
740, , 741, , 742, , 816
anterior ring, 589
anterior tubercle, 742
arch, 717, , 815
right vertebral, 821
atlas, 731
axial bone CT, 666
inferior articular facet, 721, , 722, , 723
interior arch, 722, , 723
lateral mass, 418, , 419, , 421, , 650, , 668, , 689, , 699, , 703, , 718, , 719, , 720, , 722, , 724, , 726, , 727,
, 731, , 738, , 741, , 742, , 815, , 816, , 826, , 827
normal alignment of lateral cortical margins, 719
posterior arch, 659, , 681, , 689, , 717, , 718, , 720, , 721, , 722, , 723, , 724, , 725, , 726, , 727, , 733, ,
738, , 739, , 740, , 741, , 742, , 815, , 816
posterior ring, 589
posterior turn of vertebral artery above, 589
right vertebral artery ascending, 816
root exiting above, 731
superior articular facet, 720, , 722, , 723, , 816
transverse foramen, 587, , 589, , 722, , 815, , 816
transverse process, 718, , 719, , 722, , 735, , 742
C1-C2
disc remnant, 667
intervertebral disc remnant, 668
lateral cortical margins aligning at, 718
C2 (axis), 657, , 659, , 662, , 678, , 710, , 724, , 839
axial bone CT, 667
axis, 731
bifid spinous process, 660, , 718, , 721, , 815
body, 421, , 689, , 706, , 711, , 713, , 717, , 718, , 719, , 722, , 723, , 726, , 731, , 733, , 739, , 740, , 741,
, 742, , 824, , 826, , 827
inferior, 721
odontoid base and junction of, 721, , 726
coronal bone CT, 668
distal right vertebral artery lateral, 821
facet joint, 731
foramen, 815
inferior articular facet, 689, , 722, , 733, , 735, , 739, , 741, , 816
inferior articular process, 699, , 703, , 721, , 723, , 743, , 746
inferior endplate, 743, , 746
intervertebral disc, 825
lamina, 689, , 721, , 722, , 724, , 743, , 815, , 816, , 825
lateral mass, 713
L-shaped bend through, 591
nerve, 724
neural foramen, 734
normal alignment of lateral cortical margins, 719
odontoid process, 589, , 689, , 742
pars interarticularis, 689, , 703, , 724, , 739, , 741, , 742, , 816
pedicle, 734, , 742, , 746
posterior arch, 724, , 816
pseudosubluxation, on C3, 717
root exiting, 731
spinous process, 681, , 718, , 722, , 725, , 740, , 741, , 743, , 746, , 816, , 824, , 825
lamina, 589
superior articular facet, 721, , 722, , 723
transverse foramen, 587, , 589, , 722, , 727, , 816
vertebral artery, 689, , 724, , 741
transverse process, 742
vertebral body, 730, , 746, , 815
C2-C3
disc, 743
disc space, 681, , 718
intervertebral disc, 702, , 719, , 721, , 725, , 746, , 747
joint, 724
neural foramen, 721
C3, 728, , 839
anterior cortical margin, 733
body, 717, , 718, , 723, , 728, , 733, , 734, , 735, , 743, , 825
inferior, 747
facet joint, 731
inferior articular facet, 731
inferior articular process, 699, , 703
lateral mass, 743
neural arch, 663
neural foramen, 734
pedicle, 689, , 743
pseudosubluxation, on C4, 717
root exiting, 731
superior articular facet, 689, , 733, , 735, , 739, , 741
superior articular process, 699, , 703, , 721, , 723, , 743, , 746
transverse foramen, 589, , 816
uncinate process, 721
vertebral body, 591, , 681, , 730, , 747
C3-C4
neural foramen, 738
C3-C6, 662, , 678
axial & sagittal bone CT, 669
C4, 839
body, 717, , 733, , 734, , 735, , 738, , 740
inferior endplate, 736
lamina, 689
root exiting, 731
superior articular facet, 731
superior articular process, 744
transverse process, 689, , 718
ventral ramus, 836, , 837, , 843
(intradural) vertebral artery segment, 587
vertebral body, 591, , 745
superior endplate, 744
C4-C5
facet joint, 689, , 703, , 735, , 739, , 740, , 741
intervertebral disc, 692, , 736
neural foramen, 692, , 735, , 738
C5, 840, , 841
body, 692, , 736, , 737
disc, 838
dorsal ramus, 836, , 843
dorsal root ganglion, 843
facet joint, 741
lamina, 692
neural foramen, 689, , 734
pedicle, 736, , 737
root exiting, 731
schwannoma, 843
superior articular process, 692, , 745
ventral primary ramus, 857
ventral ramus, 835, , 837, , 843
vertebral body, 591
C5-C6
facet joint, 741
C6, 837, , 840, , 841
dorsal root ganglion, 838, , 839
foramen, 815
junction of body and pedicle, 689
lamina, 734
lateral neural sulcus, 838
nerve, 838
neural foramen, 734
pedicle, 734
posterior cortical margin, 733
root exiting, 731
spinous process, 734
transverse process/foramen, 538, , 587, , 735, , 741, , 815
anterior tubercle, 738
uncinate process, 733, , 735, , 737
ventral ramus, 835, , 836, , 837, , 843
vertebra, 838
C6-C7
facet joint, 741
neural foramen, 703
C7, 662, , 678, , 728, , 837, , 840, , 841
axial bone CT, 670
body, 728
inferior articular process, 740
pedicle, 733, , 735, , 739
root exiting, 731
spinous process, 655, , 659, , 660, , 730, , 733, , 734, , 735, , 827
ventral ramus, 835, , 837, , 839, , 843
vertebrae, 843
C7-T1
facet joint, 739, , 740
neural foramen, 740
C8, 840, , 841
root exiting, 731
at C7-T1 level, 657
ventral ramus, 835, , 839, , 843
CA1
Ammon horn, 102, , 103, , 108, , 109
stratum pyramidale, 103
CA2, Ammon horn, 102, , 103, , 108
CA3, Ammon horn, 102, , 103, , 108
CA4, Ammon horn, 102, , 103, , 108
Calcarine arteries, 577, , 578, , 579, , 581, , 582, , 583, , 584, , 585, , 592
Calcarine cortex, 593
Calcarine (P4) posterior cerebral artery segment, 576, , 577, , 578, , 579, , 580, , 581, , 582, , 583
Calcarine sulcus, 29, , 30, , 33, , 34, , 39, , 44, , 45, , 287
Callosomarginal arteries, 562, , 563, , 564, , 565, , 566, , 567
Calvarial vault, 4
Calvarium, 5
Canaliculus innominatus, 400
“Cap” of arachnoid cells, 12
Carotid artery, 705, , 706, , 742, , 743, , 824, , 825, , 829
external, 813
internal, 813
Carotid body, 505
Carotid bulb
internal carotid artery, 535
with slow, nonlaminar flow, 542
Carotid canal, 374, , 400
horizontal segment, 426
temporal bone, 379
vertical segment, 374, , 426
opening, 504
Carotid canal entrance, 416
Carotid sheath, 542
with 3-layers-deep cervical fascia, 50, , 511
Carotid sinus branch (Hering nerve), vagus nerve, 508
Carotid sinus nerve, glossopharyngeal nerve, 502
Carotid space, 374
superior margin, 419
Carotid wall, 542
Cartilage endplates, 677
from adjacent vertebrae, 676
Cartilaginous anlage, 663
Cauda equina, 656, , 675, , 691, , 702, , 751, , 758, , 762, , 775, , 790–799, , 801, , 804
axial CISS and T2 MR, 796
axial T2 MR, 797
coronal CT myelogram, 793, , 794
dorsal, 798
dorsal root, 797
graphics, 791, , 792
longitudinal ultrasound, 798
nerve roots, 792, , 797
sagittal T2 and coronal stir MR, 795
thecal sac, 769, , 774
transverse ultrasound, 799
ventral, 798
ventral root, 797
Caudal anterior cingulate, 48, , 49
Caudal loop, 588
Caudal middle frontal gyrus/sulci, 48, , 49
Caudal rib head, inferior demifacet, 749
Caudal thecal sac, 780
Caudate, 90, , 263
Caudate body, 37
Caudate head, 31, , 34, , 36, , 40, , 59, , 60, , 61, , 62, , 63, , 64, , 65, , 66, , 67, , 68, , 69, , 70, , 71, , 72, ,
73, , 74, , 79, , 80, , 249, , 351
Caudate nucleus, 35, , 78, , 109, , 624
head, 44, , 315
Caudate tail, 79, , 80
Caudate vein, 626, , 630, , 632, , 635
Cavernous internal carotid artery, 119, , 120, , 122, , 381, , 382, , 389, , 404, , 407, , 424, , 446, , 466, ,
470, , 471, , 472, , 482, , 536, , 595
anterior genu, 118
Cavernous (C4) internal carotid artery segment, 550, , 551, , 555
Cavernous segment
CNVI, 480, , 481, , 482
oculomotor nerve, 451
trochlear nerve, 458
Cavernous sinus (CS), 15, , 112–123, , 355, , 407, , 414, , 424, , 452, , 453, , 456, , 466, , 470, , 471, , 472,
, 598, , 599, , 600, , 602, , 603, , 606, , 607, , 608, , 609, , 610, , 611, , 612, , 615, , 616, , 619, , 620, ,
634, , 641, , 642, , 643. See also Intracranial internal
carotid artery.
3T axial T1 C+ MR, 115–116
3T coronal T1 C+ MR, 119–120
lateral dural wall, 113, , 608
lateral wall, 17
3T sagittal fat-saturated T1 MR, 123
3T sagittal T2 MR, 121–122
sphenoparietal sinus to, 599
Cavum septi pellucidi, 40, , 351
Cavum veli interpositi, 347, , 353, , 622, , 623
CCA bifurcation, 538
Celiac trunk, 817
Central bundle, 282
Central echo complex, 798, , 799, , 804
Central gray matter, 796
spinal cord, 746
Central lobule, 331, , 337
Central precuneus, 194
Central skull base (CSB), 372, , 386, , 400–411
3T axial T1 C+ MR, 407–408
axial bone CT, 403–405
3T coronal T1 MR and T1 C+ MR, 409
graphic and clinical correlation, 411
3T sagittal T1 and T2 MR development, 410
Central spinal cord canal, 791
Central sulcus, 29, , 30, , 32, , 35, , 38, , 39, , 43, , 45, , 59, , 60, , 61, , 62, , 63, , 64, , 67, , 68, , 359
Central sulcus (rolandic) artery, 568, , 570
Central tegmental tract, 312
Central vertebral ossification center, 676
Centrum, 663, , 664, , 665, , 667, , 668, , 669, , 670, , 671, , 672, , 673
ossification, 662
Centrum semiovale, 40
Cephalad clivus, 468
Cephalad nasal cavity, 426
Cerebellar aqueduct, flow void, 311
Cerebellar artery
anterior inferior, 428, , 455
posterior inferior, 428
right superior, 305
superior, 452
Cerebellar connectivity, subgenual cingulate cortex, 211
Cerebellar flocculus, 303, , 307, , 309
Cerebellar hemisphere, 33, , 333, , 334, , 341, , 356, , 491, , 593
right inferior, 304, , 305
Cerebellar hemispheric vein, 638
Cerebellar language area, 293
Cerebellar language regions, 290
Cerebellar motor regions, 137, , 148
Cerebellar sensorimotor regions, 131
Cerebellar tonsils, 304, , 307, , 309, , 311, , 323, , 332, , 348, , 349, , 420, , 498, , 593, , 702
Cerebellar vermis, 31, , 62, , 73, , 305, , 306, , 307, , 308, , 330, , 332, , 352
Cerebellar white matter, 307, , 311, , 335, , 336
Cerebellocorticothalamic input, 92
Cerebellomedullary cisterns, 358, , 361
Cerebellopontine angle (CPA)/internal auditory canal (IAC), 321, , 338–343, , 342, , 636
axial CT, 340
3T axial T2 MR, 342
cistern, 305, , 310, , 318, , 320, , 321, , 322, , 323, , 325, , 338, , 339, , 342, , 349, , 358, , 364, , 498
facial nerve, 485
3T coronal T2 MR, 343
trigeminal nerves, 353
Cerebellum, 37, , 56, , 65, , 66, , 69, , 70, , 71, , 72, , 73, , 74, , 77, , 146, , 176, , 182, , 274, , 294, , 330–
337, , 357, , 462, , 463, , 476, , 477, , 478, , 493, , 499, , 501, , 514, , 526
adjacent CSF cisterns, 330
7T axial T1 MP-RAGE, 307–308
7T axial T1 MR, 332–333
7T axial T2 MR, 306
7T axial T2-SPACE MR, 304–305
7T coronal T2 MR, 309–310, , 334–335
flocculus, 323, , 343, , 429, , 482, , 490, , 497, , 498
lobes and lobules, 330
nuclei, 330
overview, 302–311
peduncles, 330
7T sagittal T2-SPACE MR, 311
surfaces, 330
vertebrobasilar circulation, blood supply, 330
Cerebral aqueduct (of Sylvius), 40, , 303, , 306, , 308, , 312, , 313, , 315, , 317, , 347, , 357, , 454
periaqueductal gray matter, 33, , 350
Cerebral artery, posterior, 452, , 453, , 454, , 455
Cerebral hemispheres, 28–41
axial CECT, 31, , 32
3T axial T1 MR, 34, , 35
3T coronal T1 MR, 36, , 37
3T sagittal T1 MR, 38, , 39
Cerebral peduncle, 52, , 53, , 56, , 303, , 306, , 308, , 309, , 312, , 313, , 314, , 315, , 317, , 324, , 357, ,
443, , 454, , 455, , 460
Cerebral veins, 598
Cerebral ventricles, 346
Cerebrospinal fluid (CSF), 302, , 312, , 702, , 739, , 740, , 741, , 742, , 746, , 747
in arachnoid granulation, 12
flow artifact, 759
partially fused hippocampal sulcus, 21
quadrigeminal cistern, 25
subarachnoid space, 742, , 757
thecal sac, 758, , 770, , 787
Cervical artery, ascending, 813
Cervical articular pillar, 820
Cervical bodies, 658
Cervical carotid arteries, 534–543
3D-VRT CECT, 538
graphics, 535
3T MRA, 539
ultrasound, 542–543
Cervical cord, 724, , 726, , 727, , 730, , 833
dominant segmental feeder, 820
Cervical enlargement, artery, 820
Cervical epidural venous plexus, 647
Cervical internal carotid artery, 534, , 595
Cervical lamina, 829
Cervical lateral masses “pillars, ”, 733, , 735, , 738
Cervical nerve rootlets, 833
Cervical “pillars, ”, 827
Cervical plexus, 833
Cervical spinal cord, 303, , 656, , 692, , 738, , 824
junction, 304
Cervical spine, 728–747
axial T1 C+ SPGR MR, 742–745
axial T2 gradient-echo MR, 746–747
biomechanics, 728
CT myelogram
coronal, 738
sagittal, 739
3D-VRT NECT, 735
graphics
and 3D-VRT NECT, 731
and lateral radiograph, 732
joints, 728
ligaments, 728
radiography, 733
and 3D-VRT NECT, 734
sagittal T1 MR, 740
sagittal T2 MR, 741
subaxial, components, 728
Cervical spinous process, 660
Cervical/thoracic/lumbar general musculature, 704
Cervical vertebral artery, 534
hypoplastic, 595
ramus, muscular branch, 592
Cervical vertebral bodies, 656, , 657, , 659, , 686
with cervical lordosis, 655
posterior elements, 659
Cervicomedullary junction, 791, , 795
Chamberlain line, 710, , 714, , 715
Channel, for inferior petrosal sinus, 512
Chiasm, 441
Chiasmatic sulcus, 384, , 386, , 400
Chondrocranium, 398, , 399
unossified, 388
Chorda tympani nerve, 467, , 484, , 485
Choroid, 442, , 447
globe, 564
Choroid fissure, 102, , 105, , 107
Choroid plexus, 108, , 109, , 110, , 339, , 346–357, , 583, , 600, , 623, , 627, , 628, , 629, , 632, , 638
3T axial T2 MR, 348–351
“blush, ”, 552, , 554
in body of lateral ventricle, 578
foramen of Monro, 368
glomus, 584, , 585
in atrium, “blush” of, 578
lateral recess, 352, , 602
4th ventricle, 602, , 640
in roof, of 3rd ventricle, 125
veins, 601
in roof of 3rd ventricle, 578
in temporal horn of lateral ventricle, 603
Choroid veins, 624, , 626, , 627, , 628, , 632
Choroidal arteries, 351
Choroidal fissure, 41, , 101, , 106, , 346, , 358
Choroidal fissure cyst, 23
Choroidal plexus, 102, , 103
Choroidal veins, 351
Chronic symptoms, primary motor cortex, 134
Ciliary ganglion, 452, , 467
Cingulate cingulum, 101
Cingulate cortex (areas 23, 24, 31, 32, and 33), 158
Cingulate gyrus, 30, , 35, , 36, , 37, , 39, , 40, , 42, , 45, , 47, , 92, , 101, , 104, , 107, , 110, , 200, , 294, ,
563
Cingulate hubs, 266
Cingulate sulcus, 43, , 47, , 563
Cingulum, 50, , 51, , 52
Cingulum bundle, 53, , 56, , 57, , 58, , 77
cingulate portion, 54
hippocampal portion, 54, , 57, , 58
Circle of Willis, 558–561
DSA, 561
graphics and 3D CTA, 559
7T MRA, 560
Circulus arteriosus. See Circle of Willis.
Cistern of lamina terminalis, 359
Cistern of velum interpositum, 127, , 358, , 359, , 360
internal cerebral vein, 351, , 359, , 368
Cisterna magna, 303, , 309, , 311, , 337, , 348, , 357, , 358, , 359, , 361, , 368, , 369
Cisternal portion
of CNIV, 113
of CNV, 113
Cisternal segment
accessory nerve, 516
CNVI, 480, , 481
CNVII, 484
glossopharyngeal nerve, 502
hypoglossal nerve, 520
trochlear nerve, 458, , 459
vagus nerve, 508
Cisterns, 358–369, , 514, , 526
3T axial T2 MR, 361–363
Claustrocortico projections, 55
Claustrum, 34, , 79, , 80, , 82, , 84, , 85, , 88, , 90, , 91, , 95, , 98, , 212, , 288
Clavicle, 733, , 842
Clinoid (C5) internal carotid artery segment, 550, , 551, , 555
Clinoid process
anterior, 403, , 406
posterior, 403
Clival dural venous plexus, 360
Clival occipital bone, 408, , 416, , 420
Clival plexus, 634
Clival venous plexus, 114, , 115, , 123, , 414, , 599, , 602, , 606, , 607, , 609, , 612, , 615, , 619, , 638, ,
640, , 641, , 648, , 650
Clivus, 6, , 121, , 122, , 123, , 304, , 378, , 381, , 426, , 466, , 468, , 470, , 483, , 506, , 512, , 519, , 523, ,
589, , 702, , 711, , 718, , 723, , 724, , 726, , 826
basioccipital portion, 378
basiocciput part, 404, , 407, , 417
basisphenoid part, 407
basisphenoid portion, 376
canal angle, 710
occipital bone, 379
Coactive regions, 152, , 158, , 164, , 170, , 206, , 212, , 218
temporal cortex (areas 20, 21, 22), 188
Coccygeal bodies, 657
Coccygeal plexus, 850
Coccyx (Co1-Co4), 655, , 656, , 662, , 665, , 674, , 678, , 776–787, , 779
anterior radiograph & coronal NECT, 783
axial NECT, 782
axial T2 MR, 780–781
coronal T1 MR, 784–785
coronal T2 FS MR, 786
3D-VRT NECT, 779
graphics, 777–778
lateral radiograph & sagittal T2 MR, 787
sagittal bone CT, 674
Cochlea, 310, , 325, , 342, , 376, , 486, , 489, , 492, , 493, , 497, , 500, , 501, , 515, , 527
basal turn, 343, , 487, , 488, , 489, , 491
middle turn, 343
Cochlea aqueduct, 418
Cochlear aperture (cochlear foramen), 338, , 339, , 340, , 494, , 495, , 496
Cochlear aqueduct, 341, , 487, , 524
Cochlear hearing loss, primary auditory and auditory association cortex, 242–247
Cochlear modiolus, 339, , 340
Cochlear nerve (CNVIII), 322, , 339, , 341, , 342, , 343, , 362, , 429, , 490, , 491, , 492, , 493, , 494, , 495, ,
497, , 498, , 499, , 500, , 501
injury, 338
internal auditory canal, 349
portion, CNVIII, 338
Cochlear nuclei, 425
dorsal, 339
ventral, 339
Cochleariform process, 489
Cognitive/internal stimuli, attention, 271
Collateral sulcus, 29, , 36, , 41, , 44, , 47, , 101, , 102, , 103, , 104, , 106, , 107, , 108, , 111, , 297
Collateral white matter, 101, , 102, , 103, , 104, , 106, , 108, , 109
Column of fornix, 41, , 75, , 82, , 86, , 96, , 101, , 104, , 106, , 110, , 351
Commissural callosal fibers, 51
Commissural fibers, 50
brain, 28
Commissure of fornix, 101, , 110
Common carotid artery (CCA), 511, , 531, , 534, , 535, , 536, , 539, , 651, , 838. See also Cervical carotid
arteries.
lateral DSA, 536
left, 813
lumen, 542
oblique DSA, 537
right, 815
Common facial vein, 643, , 644, , 651
Communicating (C7) internal carotid artery segment, 550, , 551, , 556, , 557
posterior communicating artery and, 555
Complicated unilateral sensorineural hearing loss (SNHL), 338
Condylar canal, 374
Condylar emissary vein, 647
Condylar fossa, 419
Condylar (lateral) occipital bone, 418
Confluence, of basal vein and vein of Galen, 127
Congenital heart disease (CHD). See also Aortic arch; Great vessels.
Connective tissue, peripheral nerve, 856
Consolidation, 294
Contrast filling contralateral anterior cerebral artery, 564
Conus, 675, , 792, , 798, , 799, , 804
tip, 805
Conus medullaris, 656, , 690, , 702, , 751, , 757, , 758, , 762, , 768, , 792, , 795
Conus tip, 797, , 798
Cord nutrient vessels, 812
Corona radiata, 32, , 35, , 36, , 37, , 41, , 50, , 52, , 53, , 55, , 56, , 57, , 58, , 59, , 60, , 61, , 62, , 63, , 64, ,
65, , 66, , 67, , 68, , 69, , 70, , 71, , 72, , 73, , 74, , 75, , 77
Coronal suture, 5, , 6, , 7, , 8, , 9
Corpus callosum, 43, , 47, , 50, , 107, , 296, , 448
body, 51, , 53, , 57, , 58, , 75
disorders of, 50
genu, 31, , 51, , 53, , 56, , 58, , 61, , 62, , 63, , 64, , 65, , 66, , 67, , 68, , 69, , 70, , 71, , 72, , 73, , 74, ,
351, , 355
rostrum, 51, , 53, , 58
splenium, 29, , 51, , 52, , 53, , 56, , 58, , 61, , 62, , 63, , 64, , 65, , 66, , 67, , 68, , 69, , 70, , 71, , 72, , 73,
, 74, , 75, , 352, , 623
Cortex of insula, 34
Cortical branches
anterior cerebral artery, 562
middle cerebral artery, 568
Cortical connections, 152, , 158
Cortical hearing loss, primary auditory and auditory association cortex, 242–247
Cortical margin odontoid process, posterior, 827
Cortical (M4) middle cerebral artery segments, 568, , 572
branches, 568, , 569, , 571, , 572
Cortical veins, 12, , 20, , 604, , 635. See also Superficial cerebral veins.
entering superior sagittal sinus, 617
in subarachnoid space, 16, , 617
unnamed, 620
venules, 617
Cortical venous tributary, in sulcus, 617
Cortical vision loss, primary visual and visual association
cortex, 182
Corticobulbar fibers, 312
Corticobulbar tract, 50, , 134, , 146
Corticohypothalamic tract, 52
Corticopontine fibers, 312
Corticopontine tract, 50, , 134
Corticorubral tract, 52
Corticospinal fibers, 312, , 313
Corticospinal tracts, 41, , 50, , 55, , 56, , 57, , 58, , 97, , 134, , 146, , 305, , 306, , 308, , 314, , 316, , 319, ,
320, , 321, , 479
Corticothalamic tract, 50
Costal element remnants, 665, , 673
Costocervical artery, right, 813
Costocervical trunk, 531, , 532
Costotransverse joint, 660, , 679, , 680, , 682, , 687, , 698, , 709, , 749, , 751, , 753, , 754, , 755
rib tubercle, 759
left, 753
right, 753
Costotransverse processes, 658
Costovertebral joint, 659, , 661, , 680, , 682, , 687, , 690, , 693, , 698, , 700, , 749, , 750, , 751, , 752, , 753,
, 754, , 757, , 758, , 759
inferior demifacet, 751, , 752, , 758
superior demifacet, 752, , 758
caudal vertebral body, 751
CPA-IAC cistern, 338
Cranial meninges, 10–17
1.5T axial T1 C+ MR, 13–14
1.5T coronal T1 C+ MR, 15
Cranial nerves (CN), 312, , 326, , 422–433
3T axial T2 MR, 428–431
graphics
global cranial nerves, 423
upper cranial nerves, 424
intracavernous, 424
lower, 425
mandibular division, 401, , 424
maxillary division, 401, , 424
nuclei, 326
ophthalmic division, 401, , 424
preganglionic segment, 423, , 424
root entry zone, 401, , 425
Craniocervical junction (CCJ), 710–727, , 728
axial T2 MR, 727
biomechanics, 710
bones, 710
components, 710
coronal T2 MR, 726
craniometry
bone CT and T1 MR, 715
graphics, 714
lateral radiography, 716
3D-VRT NECT, 722
graphics
C1, 712
C2, 713
joints, 710
lateral radiography, 717
ligaments, 710
radiography, 718
sagittal CT and MR, 725
sagittal T1 MR, 723
sagittal T2 MR, 724
Craniopharyngeal canal, 402
Cribriform plate, 373, , 384, , 386, , 387, , 391, , 395, , 396, , 397, , 398, , 399, , 403, , 423, , 426, , 436, ,
438
ethmoid bone, 377, , 379, , 380
foramen, 496
foramina, 385
site, 395
Cricothyroid muscle, innervated by superior laryngeal nerve, 510
Crista falciformis, 491
horizontal crest, 339, , 341, , 343, , 495, , 496
Crista galli, 6, , 17, , 373, , 376, , 377, , 379, , 380, , 381, , 384, , 386, , 388, , 389, , 390, , 391, , 393, , 395,
, 396, , 397, , 398, , 399, , 426, , 435, , 436, , 437, , 438
area, 394
base, 391
site, 395
site of future, 388
Cruciate ligament, 710, , 711, , 725, , 726
Crus cerebri, 96, , 312
Crus of fornix, 41, , 75, , 101, , 105, , 107, , 294
right, 126
Culmen, 331, , 337
Cuneate tubercles, 326
Cuneus, 39, , 45, , 48, , 49, , 182, , 184, , 215
Cutaneous branches, 858
D
Decision making
and prediction, orbitofrontal cortex, 170
Declarative memory, 294
Declive, 331, , 337
Dedicated complex visual, 280–281
Deep branch radial nerve, 858
Deep cerebral veins, 622–635
axial CTV, 630
coronal CTV, 631
3T coronal T1 C+ MR, 627
3D-VRT CTV, 633
graphics, 623–624
lateral and AP ICA DSA, 625
3T MIP SWI, 635
3T MRV, 634
sagittal CTV, 632
Deep facial vein, 642, , 650
Deep gray nuclei, 94–99, , 274
3T T1 MR, 97, , 98
3T T2 MR and graphic, 96
Deep middle cerebral vein (DMCV), 598, , 603, , 616, , 617, , 619, ,
620, , 621, , 627
Deep (intrinsic or “true”) muscles, 704
Deep occipital white matter, 63
Deep paramedian veins, 622
Deep vascular plexi, superficial, 5
Deep (“internal”) veins, 598
Default mode network, 256, , 257, , 258, , 264–267, , 290, , 294
default and attention control networks, 266
individual variation, 267
regions, 265
Default network, 248
Dens, 421, , 517, , 525
Dentate gyrus, 102, , 103, , 108, , 109, , 294, , 297
granular cell layer, 102, , 103
molecular layer, 103
Dentate ligament, 724, , 727, , 747
Dentate nucleus, 59, , 60, , 61, , 92, , 305, , 311, , 330, , 334, , 336
Denticulate ligaments, 791, , 796, , 800, , 802, , 808
Depression, subgenual cingulate cortex, 206
Dermis, 5, , 7
Descending occipital gyrus, 182
Descending palatine artery, 540
in pterygopalatine fossa, 535
Descending thoracic aorta, 531
Diagonal gyrus, 98, , 99
Diaphragma sellae, 13, , 113, , 114, , 424, , 466
Diencephalic membrane, 360, , 365
Digital branches, 858
Digitations of hippocampal head, 106
Diploic space, 5, , 7, , 9
of calvarium, 12
venous “lake” in, 617
Diploic veins, 642
Direct lateral vein, 624, , 625, , 630, , 631
Disc space, 682, , 683
Distal (A3) anterior cerebral artery segment, 562, , 563, , 564, , 565, ,
574
Distal common carotid artery, 542
Distal external carotid artery, lateral DSA, 540
Distal horizontal internal carotid artery canal, 379
Distal intercostal artery, 819
Distal internal carotid artery bifurcation, 557, , 560
Distal right vertebral artery, 821
Distal vagal neuropathy, vagus nerve, 508
Dopamine, 260
Dorello canal, 481
abducens nerve, 113, , 470
Dorsal anterior cingulate, 203
Dorsal attention network, 257, , 258, , 268
Dorsal brainstem, 59, , 60, , 63, , 64
Dorsal bundle, 282
Dorsal cochlear nucleus, 495
CNVIII, 327
Dorsal dural margin, 689, , 739, , 741, , 758, , 768
Dorsal epidural fat, 805
Dorsal extradural fat, 809
Dorsal extradural space, contrast, 806
Dorsal horn, 796
gray column, 517, , 791
Dorsal intermediate sulcus/septum, 791
Dorsal median sulcus/septum, 304, , 327, , 328, , 428, , 791
Dorsal muscular branch, 821
Dorsal nerve roots, 727, , 743, , 744, , 745, , 746, , 747, , 796, , 803, ,
808
sleeve outpouching, 803
Dorsal pons, 67
Dorsal premotor cortex, 146
Dorsal ramus, 813
Dorsal raphe nucleus, 262
Dorsal root, 791, , 838, , 857
Dorsal root ganglion, 770, , 771, , 775, , 809, , 838, , 856, , 857
Dorsal sacral foramen, 777, , 779, , 780, , 782
Dorsal tegmentum, 326
Dorsal vagal nucleus, 425, , 510
afferent visceral sensory, 509
CNX, 327
efferent visceral motor or parasympathetic, 509
Dorsolateral prefrontal cortex (areas 9, 46), 146, , 152, , 158–163, ,
172, , 176, , 191, , 203, , 209, , 210, , 212, , 225, , 239, , 249, , 270, ,
271, , 272, , 273, , 290, , 292
Brodmann, 163
coactivation of, 159
connectivity to, 160, , 161
Dorsolateral sulcus, 791
Dorsomedial nucleus, 92
Dorsomedial prefrontal cortex, 299
Dorsum sella, 116, , 375, , 376, , 379, , 381, , 386, , 389, , 398, , 399, ,
403, , 407, , 410, , 413, , 415
Down syndrome, posterior cingulate cortex, 194
Dura, 10, , 13, , 14, , 15, , 17, , 19, , 20, , 360, , 388, , 692, , 727, , 746, ,
747, , 759, , 792, , 797, , 800, , 801, , 803, , 804, , 809
abducens nerve, 483
inner (meningeal) layer of, 617
outer (periosteal) layer of, 16, , 617
Dura mater, 15, , 802
Dural enhancement, 15
Dural nerve root sleeve, 802, , 803
Dural sinuses, 606–615
3T AP, lateral MRV; 3D CTV, 615
3T axial T1 C+ MR, 612–614
AP ICA DSA, 610
lateral ICA DSA, 609
oblique ICA DSA, 611
Dural venous sinuses, 598
Dysesthesia, primary somatosensory cortex (areas 1, 2, 3), 128
Dyslexia
inferior parietal lobule, 236
superior parietal cortex (areas 5, 7), 140
E
Ectorhinal cortex (area 36), 218
Edinger-Westphal nucleus, 450
Emboliform (anterior) nucleus, 330
Emissary veins, 625, , 639, , 640, , 642, , 647, , 648
Emotional perception
and regulation, anterior cingulate cortex, 200
Emotional processing, orbitofrontal cortex, 170
Emotional salience, subgenual cingulate cortex, 206
Empathy, anterior cingulate cortex, 200
Encoding visual scenes, parahippocampal gyrus, 218
Endocannabinoid system, 261
Endocranial opening, petrous carotid canal, 552, , 554
Endocranial surface, 372
Endoneurium, 856, , 859
Endplate, 697, , 766
Entorhinal cortex (areas 28, 34, 35, and 36), 48, , 49, , 103, , 108, ,
176, , 218, , 294, , 296, , 297
Entorhinal region, 223
Ependymal veins, roof, 625
Epicranial aponeurosis, 5
Epicranial tissue, 4
Epidermis, 5
Epidural fat, 742, , 757, , 759, , 768, , 770, , 772, , 773, , 774, , 775, ,
797, , 802, , 805
dorsal epidural space, 694
enhancing, 744
Epidural potential space, fluid, 805
Epidural veins, 702, , 706, , 771
enhancing, 771
Epidural venous plexus, 647, , 649
Epiglottic area taste fibers, 510
Epilepsy
Epineurium, 856, , 859
Epiphysis cerebri. See Pineal region.
Episodic memory, 294
Epithalamic commissure. See Pineal region.
Epitympanic cavity of middle ear, 496
Epitympanum, 340
Erector spinae muscle, 704, , 708, , 758
Ethmoid air cells, 376
posterior, 403, , 407
Ethmoid bone, 6, , 373, , 384, , 388, , 394
cribriform plate, 386, , 393
perpendicular plate, 384, , 391, , 393, , 395, , 396, , 397
vertical plate, 394
Ethmoid nerves, anterior and posterior, 401
Ethmoid roof, 384, , 387
Ethmoid sinus, 377, , 444, , 468
developing, 396
Exiting nerve, 691, , 743, , 744, , 745, , 749, , 769, , 771, , 782
ventral sacral foramina, 782
Exocciput, 402
Exocranial opening, carotid canal, 552
Exocranial surface, 372
Expressive language, 290
External acoustic meatus, 374
External auditory canal, 340, , 487
External capsule, 52, , 56, , 57, , 58, , 75, , 79, , 80, , 82, , 84, , 85, , 88,
, 90, , 98
brain, 34
External carotid artery (ECA), 531, , 533, , 536, , 538, , 539, , 651. See
also Cervical carotid arteries.
muscular branch, 591
External digitations, 108
External jugular vein, 615, , 642, , 644, , 646, , 647, , 649, , 650, , 651
External medullary lamina, 79, , 80, , 88
External oblique muscle, 708
External occipital protuberance, 9
External table, 9
External vertebral veins
anterior, 824, , 825, , 826, , 827
posterior, 824, , 825, , 827, , 829
External vertebral venous plexus, 746, , 827
anterior, 823, , 826, , 829
posterior, 825
Extracranial internal jugular vein, 648
Extracranial segment
CNVII, 484
vagus nerve, 508
Extracranial veins, 642–651
axial CECT, 651
3T axial T1 C+ MR, 647–648
coronal CECT, 646
sagittal CECT, 645
Extradural compartment, 803, , 809
Extradural fat, 801, , 808
Extradural space, 10
Extraosseous notochord, 411
Extraosseous (V1) segment vertebral artery segment, 586, , 587
Extraspinal (V3) vertebral artery segment, 586, , 587, , 588, , 589, ,
592
above C1 ring, 591
Extrastriate visual cortex, 280
Extreme capsule, 75, , 79, , 80, , 82, , 84, , 85, , 88, , 90, , 98, , 293
brain, 34
white matter pathway, 291
F
F
Facet joints, 680, , 683, , 684, , 685, , 686, , 688, , 690, , 692, , 694, ,
695, , 696–703, , 718, , 721, , 729, , 730, , 736, , 737, , 743, , 744, ,
745, , 746, , 747, , 751, , 753, , 754, , 756, , 757, , 758, , 761, , 762, ,
763, , 764, , 765, , 766, , 769, , 770, , 775, , 794, , 829
cervical axial & sagittal NECT, 699
complex, 739
3D-VRT NECT, 698
lumbar axial & sagittal NECT, 701
sagittal T2, 702
thoracic axial & sagittal NECT, 700
zygapophyseal, 728, , 749, , 752, , 754, , 761
Facet “pillar, ”, 686, , 692, , 737
Facial artery, 531, , 534, , 535, , 536, , 537, , 539
common origin of lingual, 539
Facial colliculus, 305, , 308, , 319, , 320, , 322, , 349, , 485
Facial nerve (CNVII), 303, , 307, , 309, , 320, , 329, , 339, , 341, , 342,
, 343, , 362, , 413, , 422, , 423, , 424, , 425, , 429, , 481, , 484–493, ,
490, , 495, , 497, , 498, , 500, , 501
anterior cerebellopontine cistern, 499
anterosuperior in internal auditory canal, 499
3T axial T2 & T1 MR, 490
branches, 484
buccal branch, 485
cervical branch, 485
coronal bone CT, 488–489
CPA-IAC cistern, 338
extracranial motor, 485
injury, 338
internal auditory canal, 349
labyrinthine segment, 339, , 340, , 495, , 496
mandibular branch, 485
mastoid segment, 377
3T MR, 493
nuclei, 318
3T oblique sagittal T2 MR, 491
orientation, IAC cistern, 338
origins, 322, , 329
posterior auricular branch, 485
solitary tract nucleus, 318
superior salivatory nucleus, 318
3T T2-space MR, 492
temporal branch, 485
zygomatic branch, 485
Facial nerve canal
mastoid segment, 524
posterior genu, 486
tympanic segment, 486
Facial nerve CNVII nucleus, 64
Facial nerve paralysis, CNVII, 484
Facial nerve recess, 486, , 487
Facial veins, 605, , 615, , 642
angular branch, 643, , 644
Falciform crest, 498, , 499
Falcotentorial junction, 607
Falx cerebri, 11, , 12, , 13, , 14, , 15, , 16, , 17, , 31, , 32, , 37, , 437, ,
438, , 593, , 600, , 601
Fascicle, 856
Fastigial nucleus, 330
Fastigium, 347
Faucet. See Articular processes.
Femoral artery, 845
Femoral nerve, 845, , 846, , 847, , 848, , 849
Femoral vein, 845, , 849
Fibromyalgia, insula and parainsula areas, 176
Filiform, sheet-like trabeculae bridging subarachnoid space, 19
Filiform bridging trabeculae, 20
Filum terminale, 771, , 792, , 798, , 799, , 801, , 804
Fimbria, 41, , 101, , 102, , 103, , 104, , 105, , 106, , 107, , 108, , 109
of fornix, 294, , 297
of hippocampus, 75, , 101
Fissural segment, oculomotor nerve, 451
Flocculus, 305, , 322, , 329, , 331, , 335, , 353, , 469
cerebellum, 323, , 343
Flocculus of cerebellum, 348
Floor of sella turcica, 115, , 118
Flow void, cerebellar aqueduct, 311
Folium, 331, , 337
Fonticulus frontalis, 388, , 398
Foramen, exiting nerve within, 757
Foramen cecum, 373, , 384, , 386, , 388, , 398, , 438
area, 394
remnant, 376, , 377, , 386, , 388, , 390, , 394, , 399
Foramen lacerum, 373, , 374, , 377, , 379, , 400, , 401, , 405, , 406, ,
416, , 426
Foramen magnum, 9, , 373, , 374, , 377, , 378, , 379, , 412, , 413, ,
416, , 418, , 523, , 587, , 589, , 591, , 659, , 702, , 720, , 738
left vertebral artery, 816
marginal venous plexus of, 640
Foramen of Luschka, 328, , 329, , 348, , 428, , 827
choroid plexus, 348
Foramen of Magendie, 335, , 347, , 348, , 352, , 357
Foramen of Monro, 347, , 351, , 354, , 369, , 624, , 629
choroid plexus, 347
Foramen ovale, 373, , 374, , 377, , 378, , 379, , 382, , 387, , 400, , 401,
, 405, , 406, , 409, , 417, , 423, , 426, , 466, , 472, , 487, , 523, , 551
mandibular nerve, 474
venous plexus in, 602
Foramen rotundum, 373, , 378, , 379, , 382, , 383, , 392, , 400, , 401, ,
404, , 406, , 408, , 409, , 470, , 551
maxillary division CNV, 608
Foramen spinosum, 373, , 374, , 378, , 379, , 387, , 400, , 401, , 405, ,
417, , 423, , 426, , 468, , 487, , 523
middle meningeal artery, 408
Foraminal veins, 785
Foraminal venous plexus, 829
enhancing, 744
Foraminal (V2) vertebral artery segment, 586, , 587, , 589, , 591
Forceps major, 56, , 58
Forceps minor, 56
Fornix, 30, , 36, , 39, , 43, , 51, , 53, , 54, , 57, , 58, , 100, , 109, , 125, ,
126, , 294, , 607, , 623, , 629
anterior columns, 354, , 355
body, 353
left anterior column, 355
pillars of, 629
4th ventricle, 33, , 97, , 429, , 482, , 507, , 513, , 521
cranial nerve, 428
inferior, 428
Fovea ethmoidalis, 384, , 389, , 393, , 395, , 396, , 397, , 398, , 436
Fp1, frontal pole, 164
Fp2, frontal pole, 164
Frontal bone, 4, , 5, , 6, , 7, , 8, , 9, , 373, , 374, , 375, , 376, , 379, ,
380, , 384, , 386, , 388, , 389, , 393, , 394, , 398, , 399
orbital plate, 436
Frontal cortical veins, 14, , 614, , 618, , 619, , 621
Frontal crest, 375, , 384, , 389, , 393
Frontal eye fields (area 6), 182, , 185, , 239, , 270, , 271, , 272, , 273, ,
280, , 299
Frontal forceps, 51
Frontal gyrus, 42
Frontal horns, 346, , 347, , 350, , 351, , 354, , 355
of lateral ventricle, 109
right, 355
Frontal lobe, 36, , 38, , 39, , 42, , 388, , 389
brain, 28, , 31, , 32
Frontal nerve, 387, , 401, , 467
Frontal operculum, 34, , 38
Frontal pole (area 10), 48, , 49, , 152, , 164, , 164–169, , 197, , 198
bilateral, connectivity, 168
rendered, 169
Frontal sinus, 375, , 376, , 377, , 380, , 386, , 389, , 393, , 394, , 398, ,
399, , 438
disorders, orbitofrontal cortex, 170
Frontal sulcus, 42
Frontal white matter, 477
Frontalis muscle, 7
Frontoinsular cortex, 202
Frontomarginal gyrus, 46
Frontomaxillary suture, 8
Frontopolar artery, 562, , 563, , 564, , 567
Functional network overview, 256–259
cerebellar network parcellation, 258
functional brain network parcellation, 257
individual variation, 259
Fused sacral vertebral bodie, 657
Fusiform, 48, , 49
Fusiform gyrus (area 37), 146, , 182, , 224–229, , 298
bilateral, 227
coactivation, 225
connectivity, 226
probabilistic map, 228
G
GABA, 260
Gasserian ganglion, 119, , 608
Generalized anxiety disorder, insula and parainsula areas, 176
Geniculate fossa, 486
Geniculate ganglion, 485
Geniculate nuclei, 78
Genioglossus muscle, 522
Geniohyoid muscle (C1), 522
Genu
corpus callosum, 34, , 35, , 36, , 39, , 40, , 83
internal capsule, 40, , 80, , 81, , 82, , 83, , 86, , 87
petrous (C2) internal carotid artery segment, 551, , 552, , 553, ,
554, , 555
Geschwind territory, 54
Giant arachnoid granulation, 609, , 611
Globe, 443, , 447
Globose (posterior) nucleus, 330
Globus pallidus (GP), 34, , 36, , 40, , 41, , 73, , 74, , 78, , 79, , 80, , 81,
, 82, , 84, , 85, , 86, , 87, , 88, , 89, , 92, , 98, , 109, , 146, , 315
external segment, 91
internal segment, 91
Glossopharyngeal nerve (CNIX), 303, , 320, , 328, , 329, , 361, , 413, ,
422, , 423, , 425, , 428, , 502–507, , 509, , 511, , 513, , 514, , 515, ,
517, , 518, , 521, , 527
axial bone CT, 506
3T axial T2 MR, 507
nuclei, 326
in pars nervosa of jugular foramen, 521
Glutamate, 260
Gluteus maximus muscle, 708, , 853, , 854
Gracile nucleus, 425
Gracile tubercles, 326
Granular foveolae, 9
Gray matter formations, 312
Great cerebral vein. See Vein of Galen.
Great horizontal fissure, cerebellum, 588
Great vessels, 530–533
3D-VRT CECT, 533
left anterior oblique DSA, 532
Greater (descending) palatine artery, 541
Greater palatine foramen, 374, , 392
Greater palatine nerves, 467
Greater sphenoid wing, 5
Greater superficial petrosal nerve, 485
facial hiatus, 486
Greater wing sphenoid bone, 6, , 8
Gyral markings, 9
Gyral/sulcal, 42–49
Gyri, 28
Gyrus rectus, 33, , 36, , 42, , 46, , 381, , 386, , 387, , 389, , 390, , 397, ,
435, , 437, , 438, , 563
H
Habenula, 82, , 86
Habenular commissure, 125, , 127
Hair follicle, 5
“Hairpin” turn, of superficial temporal artery over zygoma, 539, ,
540
Hamulus, 406
“Hand knob, ”, 35
Head of caudate nucleus, 81, , 82, , 83, , 84, , 85, , 86, , 87, , 88, , 96, ,
98
Hedonic experience, orbitofrontal cortex, 170
Hemispatial neglect, 268
inferior parietal lobule, 236
Hemispheric white matter tracts, 50
Hepatic artery, 817
Heschl gyrus, 245
Heterogeneous function, 188
High jugular bulb, 340
superior margin, 340
High magnetic susceptibility, 289
High nasopharyngeal mucosal blush, 540
High-order visual processing, 188
Highest (superior) intercostal artery, 532
Hippocampal body, 37, , 40, , 41, , 104, , 106, , 109, , 110
Hippocampal commissure, 105, , 107
Hippocampal fissural cysts, 40, , 107, , 109
Hippocampal formation, 294
Hippocampal head, 33, , 36, , 40, , 41, , 104, , 109, , 110, , 354
Hippocampal subiculum, 212
Hippocampal sulcus, 102, , 297
Hippocampal tail, 34, , 41, , 107, , 109, , 110, , 297
Hippocampus, 38, , 47, , 54, , 84, , 85, , 86, , 96, , 100, , 107, , 111, ,
158, , 176, , 262, , 265, , 294, , 299, , 356, , 463
head, body, and tail, 101
Horizontal (A1) anterior cerebral artery segment, 559, , 560, , 562, ,
563, , 565, , 566
left, 559, , 560
Horizontal (petrosal) cerebellar fissures, 331, , 335, , 336, , 337. See
also Cerebellum.
Horizontal (M1) middle cerebral artery segment, 560, , 568, , 569, ,
571, , 572, , 573, , 574, , 575
Horizontal/petrosal fissure, 303, , 309, , 311
Horizontal petrous carotid canal, 519
Horizontal petrous internal carotid artery, 376, , 408, , 415, , 474
anterior genu, 408
canal, 377, , 404, , 419, , 506, , 512
Horizontal segment petrous internal auditory canal, 489
Humerus, 858
Hyaline cartilage, 697
Hyoglossus muscle, 475
Hypoglossal artery, persistent, 595
Hypoglossal canal, 328, , 373, , 378, , 412, , 413, , 417, , 418, , 421, ,
423, , 426, , 428, , 487, , 488, , 523, , 524, , 525, , 595, , 719, , 723, ,
724, , 726
entrance to, 521
external opening, 419
inferior margin, 417
Hypoglossal cisternal rootlets, 521
Hypoglossal cisternal segment, 521
Hypoglossal eminence, 304, , 327, , 328, , 329, , 521
Hypoglossal intraaxial axons, 521
Hypoglossal nerve (CNXII), 303, , 327, , 328, , 413, , 420, , 421, , 422,
, 423, , 425, , 428, , 503, , 504, , 509, , 511, , 517, , 520–527
axial bone CT and 3T T2 MR, 523
in distal hypoglossal canal, 525
graphics
extracranial, 522
intracranial, 521
in hypoglossal canal, 521, , 525
location, 524
3T MR tractography, 527
in nasopharyngeal carotid space, 521
nuclei, 326
rootlet, 523
3T T2-space MR, 526
Hypoglossal nucleus, 327, , 425, , 520, , 521, , 522
location, 523
Hypoglossal trigone, 428
Hypoglossal venous plexus, 640, , 646, , 648
draining into left IJV, 646
in hypoglossal canal, 649
within hypoglossal canal, 650
Hypophysis, 113. See also Pituitary gland.
Hypoplastic anterior communicating artery, 567
Hyporeflexia, primary motor cortex, 134
Hypothalamus, 47, , 84, , 88, , 104, , 110, , 206, , 230, , 263, , 297, ,
298, , 365, , 366, , 448
median eminence, 354
I
Iliac artery, 708
Iliac crest, 762, , 780, , 781
Iliac vein, 708
Iliac wing, 657, , 660, , 661, , 673
Iliacus muscle, 708, , 845
Iliocostalis muscle, 707, , 708
Iliohypogastric nerve, 845
Ilioinguinal nerve, 845
Ilium, 708, , 782, , 783, , 785, , 787
Impulse control, anterior cingulate cortex, 200
Incisive foramen, 374
Incus, short process, 486
Indusium griseum, 101, , 105, , 294
Inferior alveolar artery, 535, , 536, , 540
Inferior alveolar nerve, 401, , 467, , 475
Inferior annular epiphysis, 663, , 664
Inferior articular facet, 681, , 684, , 712, , 713, , 729, , 736, , 737, ,
754, , 755, , 756, , 761, , 766
joint between superior articular facets, 655
Inferior articular process, 658, , 679, , 683, , 685, , 686, , 688, , 690, ,
691, , 693, , 694, , 695, , 697, , 698, , 699, , 700, , 701, , 729, , 751, ,
757, , 758, , 761, , 762, , 763, , 764, , 765, , 766, , 767, , 769, , 770, ,
775
Inferior bony endplate, 679, , 749
Inferior (suboccipital) cerebellar fissures, 330. See also Cerebellum.
Inferior cerebellar hemisphere, 59, , 60, , 61, , 62, , 63, , 64, , 67, , 68,
, 309, , 311, , 332, , 336
Inferior cerebellar peduncle, 53, , 56, , 61, , 62, , 302, , 305, , 307, ,
320, , 322, , 326, , 329, , 330, , 331, , 332, , 428, , 429, , 479, , 482, ,
507
Inferior colliculus, 33, , 126, , 127, , 306, , 311, , 313, , 314, , 460, , 461
lateral lemniscus, 92
Inferior cortical margin, 683
lamina, 683
pedicle, 682
Inferior cruciate ligament, 727
Inferior demifacet
caudal rib head, 679
rib, 687, , 690
Inferior endplate, 681, , 682, , 688, , 690, , 691, , 694, , 700, , 701, ,
750, , 757, , 758, , 764, , 765
Inferior extension cruciate ligament, 711
Inferior frontal gyrus (areas 44, 45, 47), 29, , 30, , 32, , 36, , 42, , 43, ,
44, , 46, , 47, , 152, , 176, , 182, , 191, , 248–253, , 270
Brodmann areas, 252–253
connectivity, 250–251
location and coactivation, 249
pars opercularis, 45
pars orbitalis, 45
pars triangularis, 45
Inferior hypophyseal artery, 551
Inferior internal parietal arteries, 562
Inferior jugular foramen, 426, , 523
Inferior lamina of pineal stalk, 127
Inferior longitudinal fasciculus, 50, , 52, , 55, , 57, , 58
Inferior medulla, 332
Inferior medullary velum, 311, , 331, , 337
Inferior oblique capitis muscle, 706
Inferior oblique muscle, 442
Inferior occipital gyrus, 32, , 44, , 45, , 46, , 47, , 182
Inferior occipitofrontal fasciculus, 50, , 52, , 55, , 57, , 58
Inferior olivary nucleus, 327, , 521
Inferior olivary nucleus area, 513
Inferior ophthalmic vein, 115, , 442, , 602, , 642, , 643
Inferior orbital fissure, 5, , 377, , 378, , 391, , 392, , 400, , 408, , 426, ,
468
Inferior parietal gyrus/sulci, 48, , 49
Inferior parietal lobule, 29, , 92, , 152, , 158, , 164, , 172, , 174, , 176, ,
236–241, , 299
angular and supramarginal gyri, 240
functional connectivity, 238–239
location, 241
and coactivation, 237
Inferior petrosal sinus (IPS), 377, , 414, , 420, , 598, , 599, , 602, ,
606, , 607, , 612, , 615, , 619, , 620, , 623, , 637, , 638, , 640, , 650, ,
826
Inferior rectus muscle, 442, , 444, , 447
Inferior sagittal sinus (ISS), 11, , 14, , 598, , 599, , 606, , 607, , 609, ,
610, , 611, , 614, , 619, , 620, , 623, , 625, , 626, , 628, , 637
Inferior salivatory nucleus, 425, , 503, , 505
Inferior (suboccipital) surface, 336
Inferior temporal gyrus, 29, , 30, , 32, , 36, , 42, , 44, , 45, , 47, , 48, ,
49, , 156, , 164, , 174, , 190, , 193
Inferior temporal lobe, 299
Inferior temporal sulcus, 193
Inferior thyroid artery, 532
thyrocervical trunk, 531, , 532
Inferior vena cava, 769, , 770, , 771, , 774, , 775, , 823
iliac veins, 771
Inferior vermian artery, 592
posterior inferior cerebellar artery, 588
Inferior vermian vein, 632, , 636, , 637, , 638, , 639, , 640
Inferior vestibular nerve, 322, , 339, , 341, , 342, , 429, , 490, , 491, ,
495, , 497, , 499
Inferior vestibular nucleus, 495
Inferior visual field, 285
Inferolateral temporal cortex, 265, , 266
Inferolateral trunk, 535, , 551, , 552
Infraorbital artery, 535, , 540
Infraorbital foramen, 5
Infraorbital nerve, 381, , 401, , 404, , 442, , 444, , 467
Infratemporal fossa, 377
Infratentorial (posterior fossa) cisterns, 358
Infundibular recess, 456
Infundibular stalk, 603
hypothalamus, 559
Infundibulum (pituitary stalk), 113, , 114, , 116, , 117, , 119, , 121, ,
123, , 381, , 446, , 472
upper aspect, 119
Inguinal ligament, 845
Inner pial layer, 19
Innominate artery, 813
Innominate vein, 829
Insula, 42, , 44, , 49, , 88, , 152, , 180, , 230, , 272, , 288. See also
Middle cerebral artery.
brain, 28, , 33, , 34, , 36, , 37, , 41
Insula and parainsula areas (areas 13, 43), 176–181
coactivation, 177
functional connectivity to, 180
functional parcellation of, 178
functional subregions of, 179
location, 177, , 179, , 181
Insular cortex, 47, , 79, , 297
Insular (M2) middle cerebral artery segments, 568, , 569, , 571, ,
572, , 574, , 575
angiographic sylvian “triangle, ”, 570
anterior trunk, 573
apex of, 572
delineate apex of sylvian fissure, 569
posterior trunk, 573
Insular veins, 603, , 620
Intact genu and anterior corpus callosum, 77
Intact splenium, 77
Intercavernous plexus, 603
Intercavernous sinus, 607, , 608
anterior & posterior, 599
Intercavernous venous sinus, 13
Intercostal artery, 814
Intercostal muscle, 709
Intercostal nerves, 657
Interdigitations of hippocampal head, 41
Interdural segment
CNVI, 480
trigeminal nerve, 464
Interhemispheric fissure, 29, , 33, , 35, , 355, , 358, , 559, , 563, , 565
A2 anterior cerebral artery segment, 368
Intermediate olfactory stria, 435
Intermediate sacral crest, 779
Intermediolateral column, 791, , 796
Internal acoustic meatus, 373, , 412
Internal auditory canal, 310, , 324, , 325, , 343, , 349, , 376, , 381, ,
415, , 419, , 423, , 471, , 482, , 485, , 486, , 488, , 489, , 496, , 524, ,
525, , 636
anterior margin of, 491
cistern, 338
CNVII, 349, , 353
CNVIII, 349, , 353
fundus, 338, , 339, , 340, , 342, , 343
Internal auditory canal fundus, facial nerve, 486, , 491
Internal auditory meatus, 9
Internal capsule, 36, , 50, , 52, , 57, , 58, , 79, , 80, , 84, , 85, , 88, , 98
Internal capsule region, 60
Internal carotid artery (ICA), 80, , 113, , 115, , 116, , 117, , 332, , 382,
, 420, , 446, , 453, , 454, , 456, , 460, , 504, , 511, , 523, , 531, , 546, ,
560, , 561, , 569, , 576, , 586, , 642, , 647, , 648, , 650, , 727. See also
Cervical carotid arteries; Intracranial internal carotid artery.
cervical segment, 536
“fetal” origin of posterior cerebral artery from, 580
left, 559
right, 559
contrast reflux, 821
Internal carotid artery lumen, 542
Internal cerebral vein (ICV), 31, , 125, , 126, , 127, , 352, , 353, , 567, ,
574, , 583, , 598, , 599, , 601, , 604, , 605, , 606, , 607, , 609, , 610, ,
611, , 613, , 614, , 615, , 620, , 621, , 622, , 623, , 624, , 625, , 626, ,
627, , 628, , 629, , 630, , 631, , 632, , 633, , 634, , 635, , 637, , 638, ,
826, , 827
cistern of velum interpositum, 351
within cistern of velum interpositum, 125, , 127
medullary, subependymal veins to, 599
quadrigeminal cistern, 363
velum interpositum, 628
Internal digitations, 108
Internal jugular vein (IJV), 414, , 420, , 421, , 504, , 511, , 525, , 598, ,
605, , 607, , 609, , 615, , 634, , 637, , 640, , 642, , 643, , 644, , 645, ,
647, , 651, , 824, , 826, , 827
bulb, 618, , 649
left, 646
right, 646, , 815
Internal mammary artery, left, 813
Internal maxillary artery, 408, , 551
AP DSA, 541
Internal medullary lamina, 79, , 92
Internal narrative, posterior cingulate cortex, 194
Internal oblique muscle, 708
Internal occipital crest, 413, , 415
Internal occipital protuberance, 6
Internal stimuli, attention to, retrosplenial cingulate cortex, 212
Internal table, 9
Internal thoracic (mammary) artery, 531, , 532, , 533
Internal vertebral vein
anterior, 824, , 825, , 826, , 827
Internal vertebral venous plexus, 742, , 743, , 746
anterior, 823, , 824, , 825, , 826, , 827
enhancing, 744, , 745
posterior, 823, , 824, , 825, , 827
Interosseous sacroiliac ligament, 781, , 782
Interpeduncular cistern, 116, , 121, , 306, , 308, , 309, , 314, , 315, ,
316, , 317, , 323, , 324, , 353, , 358, , 359, , 360, , 362, , 364, , 368, ,
369, , 460, , 471
CNIII, 369
junction with suprasellar cistern, 365
oculomotor nerve, 450, , 454, , 455
Interpeduncular fossa, 33, , 313, , 454
Interscalene triangle, 833
Intersphenoidal synchondrosis, 402, , 410, , 411
Interspinalis muscle, 704, , 706, , 707, , 708
Interspinous ligament, 678, , 679, , 684, , 689, , 690, , 693, , 695, ,
709, , 730, , 739, , 740, , 741, , 756, , 757, , 758, , 768, , 770, , 771, ,
774
Interthalamic adhesion, 363
Intertransverse ligaments, 678
Intervertebral disc, 654, , 655, , 656, , 658, , 675, , 676, , 677, , 684, ,
685, , 686, , 687, , 688, , 690, , 694, , 695, , 696–703, , 728, , 729, ,
730, , 735, , 739, , 749, , 751, , 752, , 753, , 756, , 757, , 758, , 766, ,
767, , 768, , 818
cervical axial & sagittal NECT, 699
3D-VRT NECT, 698
L3-L4, 770
lumbar axial & sagittal NECT, 701
sagittal T2, 702
space, 682, , 698, , 733, , 738
thoracic, 702
thoracic axial & sagittal NECT, 700
Intervertebral disc space, 750, , 763, , 764, , 765
Intervertebral foramen, 728
Intima, 542
Intraaxial segment
CNVI, 480
vagus nerve, 508
Intracochlear lesion, suspected, vestibulocochlear nerve, 494
Intracranial arteries, 546–549
brain
anterior cerebral artery, 562–567
middle cerebral artery, 568–575
posterior cerebral artery, 576–585
vertebrobasilar system, 586–595
graphic and 7T MRA, 547
Intracranial internal carotid artery, 550–557
AP DSA, 554
CTA, 557
3D-VRT CTA, 556
lateral DSA, 552
3T MRA, 555
oblique DSA, 553
Intracranial venous system overview, 598–605
axial CECT, 600–601
3T axial T1 C+ MR, 602–604
graphics, 599
3T lateral, oblique, and AP MRV, 605
Intradural veins, 822
Intradural venous channels, 617
Intradural (V4) vertebral artery segment, 586, , 588, , 591
right, 815
Intramesencephalic segment
oculomotor nerve, 450
Intranuclear cleft, 702
Intraorbital (extracranial) segment, CNVI, 480
Intraparietal sulcus (area 5, 7), 32, , 43, , 47, , 142, , 146, , 158, , 159,
, 160, , 161, , 162, , 182, , 212, , 225, , 226, , 227, , 239, , 249, , 270, ,
271, , 272, , 273, , 280, , 292, , 298, , 299
Intratemporal segment, CNVII, 484
Intrathalamic adhesion, 92
Intravertebral venous sinuses, 829
Intrinsic tongue muscles, 522
Isthmus (retrosplenial cortex), 45, , 48, , 49
of cingulate gyrus, 29, , 30
and cingulum, 101
J
J
Jacobson nerve, sensory from middle ear and
parasympathetic to parotid gland via, 505
Joints of Luschka, 728
Jugular bulb, 414, , 415, , 420, , 421, , 525, , 602, , 605, , 607, , 609, ,
612, , 615, , 623, , 634, , 640, , 645, , 646, , 648, , 827
within jugular foramen, 420
roof, 376
Jugular foramen, 307, , 328, , 343, , 373, , 374, , 376, , 377, , 381, ,
412, , 413, , 414, , 415, , 416, , 418, , 419, , 423, , 426, , 428, , 468, ,
488, , 507, , 512, , 517, , 524, , 525, , 650, , 719
bulbar and spinal fibers combine in CNXI in, 517
jugular bulb within, 420
Jugular fossa, 504
Jugular spine, 413, , 415, , 426, , 503, , 506, , 512, , 519
Jugular tubercle (“bird’s head and beak”), 343, , 377, , 379, , 412, ,
413, , 418, , 419, , 421, , 506, , 512, , 524, , 525, , 650, , 723
Jugular vein, 599, , 705, , 706, , 825, , 826
K
Kerckring ossicle, 412
Klüver-Bucy syndrome, temporal pole, 230
L
L1
lumbar artery, 819
nerve root, 762
pedicle, 762, , 817
vertebral body, 768
L2, 846
nerve, 772
pedicle, 772
L2-L3 foramen, L2 nerve in, 703
L3, 795, , 846
dorsal root ganglion, 762
inferior articular process, 763, , 770, , 772
lamina, 772
nerve, 773, , 774
dorsal ramus, 772
ganglion, 772
root, 768, , 775
nerve root, 801
pedicle, 772
L3-L4 intervertebral disc, 703
L4, 778, , 795, , 846, , 851
dural root sleeve and nerve, 801
inferior articular process, 703, , 772, , 775
lamina, 772
minor branch, 847
nerve, 773, , 774
dorsal ramus, 772
nerve ganglion, 774
pedicle, 773, , 801
root, 762
exiting at L4-5 level, 657
superior articular process, 763, , 768, , 770, , 771
L5, 778, , 795, , 846, , 847, , 848, , 849, , 851
body, 762, , 763, , 768, , 779, , 783, , 787
disc, 787
exiting under pedicle, 694
inferior articular facet, 780
intervertebral disc space, 763
intradural nerve, 762
nerve, 773, , 787
nerve ganglion, 773
nerve root, 768, , 809
neural foramen, 785
pars interarticularis, 763
pedicle, 762, , 768, , 773, , 809
S1 disc, 779, , 780, , 783
S1 vertebral body, 785
spinous process, 779, , 787
transverse foramen, 779
transverse process, 772, , 779, , 783
vertebral body, 785
Labyrinthine segment, facial nerve, 485, , 486, , 489
Lacerum (C3) internal carotid artery segment, 550, , 551, , 552, ,
553, , 555
Lacrimal artery, 442
Lacrimal bone, 5
Lacrimal gland, 447
Lacrimal nerve, 401, , 442, , 467
Lambda, 4, , 7, , 8, , 9
Lambdoid suture, 6, , 7, , 8, , 9
Lamina, 658, , 660, , 679, , 680, , 682, , 683, , 684, , 685, , 686, , 687, ,
688, , 692, , 693, , 694, , 695, , 698, , 699, , 700, , 701, , 705, , 709, ,
713, , 721, , 729, , 736, , 737, , 740, , 744, , 745, , 746, , 747, , 749, ,
751, , 752, , 753, , 754, , 756, , 757, , 758, , 759, , 761, , 763, , 764, ,
765, , 766, , 767, , 769, , 770, , 774, , 775, , 794, , 823
ligamentum flavum, 692
Lamina cribrosa, 384
Lamina papyracea, 376, , 377, , 390, , 393
Lamina terminalis, 30, , 347, , 350, , 366, , 368
cistern, 363, , 366, , 367, , 368
Language network, 290–293
spoken and written, 292
white matter pathways, auditory, 293
Lateral annulus fibrosus, 691
Lateral atlantoaxial joint, 710, , 711
Lateral atrial vein, 625, , 626, , 627, , 629, , 632, , 635
Lateral columns or “pillar, ”, 681
Lateral dural wall, 456
of Meckel cave, 117
Lateral femoral cutaneous nerve, 845
Lateral fissure, 43, , 358
Lateral geniculate body, 92, , 282, , 441, , 443
Lateral geniculate nucleus, 37, , 283, , 449
thalamus, 280
Lateral internal carotid artery, DSA, 619
Lateral lamella, 391, , 393, , 395, , 397, , 436
Lateral lemniscus, 312
Lateral lenticulostriate arteries, 19, , 80, , 549, , 567, , 568, , 569, ,
571, , 575
right, 575
Lateral mass, 666
Lateral medullary segment, 588
Lateral mesencephalic vein, 461, , 600, , 629, , 637, , 638, , 641
Lateral neural recess, 737
nerve root, 745
Lateral neural sulcus, 833, , 838
Lateral occipital sulcus, 46, , 48, , 49, , 226
Lateral occipitotemporal gyrus, 29
Lateral olfactory stria, 434, , 435
Lateral orbitofrontal cortex, 170
Lateral pectoral nerve, 836
Lateral posterior choroidal artery, 577, , 578, , 582, , 583, , 584, , 585,
, 588, , 592, , 632
Lateral premotor cortex, 191, , 290, , 292, , 293
Lateral pterygoid muscle, 382, , 467, , 472, , 475
Lateral pterygoid plate, 383
Lateral putamen, 60
Lateral rectus muscle, 441, , 442, , 443, , 444, , 447
Lateral sacral crest, 779
Lateral semicircular canal, 375, , 485, , 488, , 489, , 496, , 524
Lateral sensorimotor cortex, 149
Lateral sulcus (Sylvian fissure), 29, , 33, , 44
Lateral tegmental NE cell system, 262
Lateral vein, 624
draining into terminal vein, 627
Lateral ventricles, 107, , 111, , 325, , 346, , 354, , 628, , 632
atrium, 351, , 352, , 356
choroid plexus, 350, , 351, , 352
choroid plexus glomus, 351
body, 346, , 347, , 351, , 353, , 357
choroid plexus, 352, , 354, , 357
choroid plexus, 353
frontal horn, 624
vein, roof, 625
Lateral ventricular atria, choroid plexus, 351
Lateral vestibular nucleus, 495
CNVIII, 327
Latissimus dorsi muscle, 704, , 707
Left anterior cerebral artery, 574
A1 segment, 117, , 119, , 567
A2 segment, 566, , 567
Left anterior cingulate cortex, connectivity to, 203
Left anterior clinoid process, 118
Left anterior inferior cerebellar artery-posterior inferior cerebellar
artery trunk, 547, , 588, , 594
Left Brodmann area, 10, connectivity to, 166
Left cavernous internal carotid artery, 117, , 118
Left common carotid arteries (LCCA), 530, , 532, , 533, , 538. See
also Aortic arch; Great vessels.
Left common iliac artery, 769
Left external carotid artery, 538
Left foramen ovale, 119
Left inferior frontal gyrus, 298
Left middle cerebral artery, 119, , 547
Left oculomotor nerve, 118
cistern, 118
Left optic nerve, 118
Left optic tract, 117
Left orbitofrontal cortex, connectivity to, 172
Left subclavian arteries (LSCA), 530, , 531, , 532, , 533, , 587. See also
Aortic arch; Great vessels.
arise from aortic arch, 531
from brachiocephalic trunk, 531
Left subgenual cingulate cortex, connectivity to, 210
Left superior colliculus, 126
Left supraclinoid carotid artery, 117
Left supraclinoid internal cerebral artery, 117, , 118
Left transverse sinus, 611, , 615
Left vertebral artery, 532, , 533, , 539, , 590
arises from aortic arch, 531
unopacified blood in, 593
Left visual field, 285
Lenticulostriate arteries, 547, , 560, , 568
Lentiform nucleus, 31, , 59, , 60, , 61, , 62, , 63, , 64, , 65, , 66, , 67, ,
68, , 69, , 70, , 71, , 72, , 80
Leptomeninges, 10, , 18
Lesser palatine nerves, 467
Levator palpebrae muscle, 387, , 442, , 452, , 459
Levator palpebrae superioris, 444, , 447
Levator scapulae muscle, 704, , 705, , 706
Ligaments, 654, , 678
Ligamentum flavum, 678, , 679, , 684, , 690, , 691, , 692, , 693, , 694, ,
695, , 701, , 757, , 758, , 759, , 766, , 767, , 768, , 769, , 770, , 771, ,
772, , 774, , 780
Ligamentum nuchae, 689, , 706, , 711, , 730, , 739, , 740, , 741
Liliequist membrane, 114, , 358, , 365, , 366, , 368, , 369, , 456
attachment at oculomotor nerve, 365
sellar segment, 360
Limbic lobe, 100
Limbic network, 257, , 258, , 288–289
Limbic system, 28, , 100–111
3T aging and Alzheimer examples, 111
3T axial T2 MR, 109
histology, 102
16.4T postmortem ultrahigh field MR, 103
Line dividing anterior, 386
Lingual artery, 534, , 535, , 536, , 537, , 539
Lingual branch, glossopharyngeal nerve, 502
Lingual gyrus, 33, , 44, , 45, , 48, , 49, , 182
Lingual nerve, 401, , 467
Lingula, 331, , 337
Lobes, 28
Locus coeruleus (LC), 94, , 97, , 99, , 262
Long ciliary nerve, 467
Long thoracic nerve, 836
Longissimus capitis muscle, 706
Longissimus muscle, 705, , 707, , 708
Longissimus thoracis muscle, 709
Longitudinal fissure, brain, 37
Longus capitis muscle, 704, , 705, , 706, , 742, , 743, , 746
Longus colli muscle, 704, , 705, , 706
Lumbar bodies, with lumbar lordosis, 655
Lumbar facet joint, 660
Lumbar inferior articular process, 660
Lumbar intervertebral discs, 657, , 661
Lumbar neural foramen, 659
Lumbar pedicle, 661
Lumbar plexus (LP), 844–849
axial T1 MR, 848
axial T2 FS MR, 849
coronal T1 MR, 846
Lumbar segmental artery
left, 818
right, 818
Lumbar spine, 760–775
1.5T axial T1 MR, 769
1.5T axial T2 MR, 774
3D-VRT NECT, 764, , 765
3T axial T1 C+ FS MR, 771
3T axial T1 MR, 770
3T axial T2 MR, 775
axial bone CT, 766, , 767
coronal T1 MR, 772, , 773
radiography, 763
sagittal T1 MR, 768
Lumbar spinous process, 659, , 660
Lumbar superior articular process, 660
Lumbar transverse process, 660
Lumbar vertebra (L1-L5), 662
axial bone CT, 672
Lumbar vertebral bodies, 656, , 657, , 658, , 659, , 661
Lumbosacral junction, 776
Lumbosacral plexus (LSP), 657, , 844, , 845, , 850
Lumbosacral trunk (LST), 778, , 844, , 845, , 846, , 850, , 851
M
Macula cribrosa, 340
Macula cribrosa foramen, 496
Magnocellular red nucleus (mcRN), 94
Main sensory nucleus, trigeminal nerve, 464, , 465
Main trunk of external carotid artery, 542
Major depressive disorder
superior prefrontal cortex, 152
Malleus, 489
head, 486
Mammillary bodies, 39, , 40, , 47, , 101, , 104, , 108, , 109, , 110, , 114,
, 121, , 294, , 309, , 323, , 454, , 460
Mammillary process, 766
Mammillothalamic tract, fornix, 92
Mandibular condyle, 378, , 417, , 475, , 487
Mandibular division, trigeminal nerve (CNV3), 382, , 464, , 465, ,
470, , 471, , 472, , 475
anterior division, 467
entering foramen ovale, 467
foramen ovale, 468
main trunk, 467
meningeal branch, 468
posterior division, 467
Mandibular foramen, inferior alveolar nerve, 475
Mandibular head, 419, , 420
Mandibular nerve (CNV3), 119, , 381, , 401, , 408, , 409
entering foramen ovale, 114
exiting foramen ovale, 119
in foramen ovale, 408
surrounded by pterygoid venous plexus, 648
Mandibular ramus, marrow space, 475
Mandibular vein, 647
Marginal branch of cingulate sulcus, 45
Marginal ramus of cingulate sulcus, 43
Marrow space foci, 338
Massa intermedia, 81, , 82, , 357, , 363
location, 347
Masseter muscle, 467, , 475
Masseteric artery, 540
Masseteric branches, buccal, 540
Masticator space, 374, , 392, , 504
Mastoid air cells, 375, , 376, , 415, , 418, , 524
temporal bone, 375
Mastoid antrum, 340, , 486, , 488, , 496
Mastoid emissary vein, 420
Mastoid process, 6, , 8, , 9, , 374, , 379, , 418, , 735
Mastoid segment, 418
CNVII, 496
facial nerve, 486, , 487, , 488
Mastoid sinuses, 490
Mastoid tip, 378, , 417, , 487, , 488, , 524
Maxilla, 8
Maxillary artery, 534, , 535, , 537, , 539, , 540, , 645
branching within pterygopalatine fossa, 536
in pterygopalatine fossa, 537, , 539, , 541
Maxillary bone, 374
Maxillary division, trigeminal nerve (CNV2), 115, , 120, , 382, , 401, ,
408, , 464, , 465, , 466, , 471, , 472, , 473
entering foramen rotundum, 114
foramen rotundum, 467, , 468, , 470, , 473
infraorbital nerve, 465, , 474
Maxillary sinus, 381, , 392, , 408, , 444, , 468, , 474
McGregor line, 710, , 714, , 715, , 716
McRae line, 710, , 714, , 716
Meckel cave, 114, , 115, , 117, , 118, , 119, , 305, , 321, , 322, , 323, ,
342, , 365, , 366, , 381, , 407, , 408, , 429, , 445, , 446, , 456, , 465, ,
466, , 467, , 469, , 470, , 472, , 474, , 482, , 608
CNV fascicles, 362, , 366
dural margin, 471
dural wall of, 367
lateral dural margin, 469
right, 612
trigeminal fascicles, 474
Media, 542
Medial atrial vein, 625, , 626, , 629, , 630, , 635
Medial basal canal, 411
Medial forebrain bundle, 434
Medial frontal gyrus, 30
Medial geniculate body, 92, , 441
Medial habenular nucleus, 262
Medial intraparietal sulcus, 283
Medial lemniscus, 53, , 56, , 57, , 58, , 312, , 319, , 479
spinothalamic tracts, 92
Medial lenticulostriate arteries, 80, , 549, , 562, , 565, , 567, , 569
left, 575
Medial longitudinal fasciculus, 97, , 305, , 306, , 308, , 312, , 313, ,
314, , 316, , 319, , 321, , 327
Medial occipitotemporal gyrus, 29
Medial olfactory stria, 434, , 435
Medial orbital frontal gyrus/sulci, 48, , 49
Medial orbitofrontal cortex, 170, , 299
Medial posterior choroidal artery, 125, , 360, , 577, , 578, , 583, , 585,
, 588, , 592, , 623
Medial prefrontal cortex, 156, , 238, , 265, , 266, , 298
Medial pterygoid muscle, 382, , 467, , 472, , 475
Medial pterygoid plate, 383
Medial rectus muscle, 441, , 442, , 443, , 444, , 447
Medial rib, 693, , 757, , 821
Medial septal nuclei, 262
Medial superior parietal areas, 142
Medial vestibular nucleus, 495
CNVIII, 327
Median atlantoaxial joint, 710
anterior articular facet, 713
Median eminence, 121
hypothalamus, 114, , 354
Median nerve, 835, , 836, , 857, , 858
Median sacral crest, 779, , 780, , 782, , 787
Mediodorsal nucleus of thalamus, 158
Medulla, 61, , 62, , 302, , 303, , 309, , 310, , 311, , 323, , 326–329, ,
332, , 337, , 348, , 353, , 361, , 428, , 483, , 525, , 827
3T axial T2 MR, 328–329
external features, 326
junction, 304
ventral (anterior), 326
Medulla oblongata, 110, , 420, , 461, , 498
Medullary arteries, 814
Medullary branches, 813
Medullary cistern, 304, , 348, , 357, , 359, , 368
vertebral artery, 348
Medullary olive, 303, , 304, , 307, , 320, , 325, , 327, , 328, , 329, , 428,
, 507
Medullary pyramids, 303, , 304, , 307, , 320, , 325, , 327, , 328, , 507, ,
513, , 519, , 523, , 526
Medullary vein, 622, , 627
deep white matter, 624, , 633
white matter, 625, , 635
Medullary veins, 610, , 823
Memory
superior parietal cortex (areas 5, 7), 140
Memory network, 294–297
limbic and medial temporal anatomy, 296
medial temporal MR anatomy, 297
Meningeal branch CNXII, 522
Meningeal dural layer
inner, 12
passing into optic, 13
Meningeal lymphatics, 12
Meninges, 654, , 800–809
axial CT myelogram, 803
axial T1 C+ MR, axial and coronal T1 MR, 809
axial T2 MR, 808
longitudinal and transverse ultrasound, 804, , 805
sagittal and axial CT myelogram, 806, , 807
Meningohypophyseal arteries, inferior hypophyseal, 535
Meningohypophyseal trunk, 551, , 552
tentorial branch, 580
Mental foramen, 475
Mentalizing, subgenual cingulate cortex, 206
Mesencephalic membrane, 360
Mesencephalic nucleus, 425
Mesencephalon. See also Midbrain.
Mesotympanum, 340
Metopic suture (obliterated), 8
Meyer loop, 283, , 449
inferior (ventral) bundle, 282
Mid cingulate cortex, 201, , 299
Mid inferior insula, 178
Mid superior insula, 178
Midbrain (mesencephalon), 31, , 33, , 44, , 123, , 302, , 303, , 311, ,
312–317, , 333, , 337, , 350, , 454, , 460, , 461
7T axial T1 MR, 314–315
7T axial T2 MR, 316–317
perivascular spaces, 316
thalamic “blush, ”, 578
Middle cerebellar peduncle (brachium pontis), 53, , 56, , 57, , 58, ,
63, , 64, , 65, , 66, , 67, , 69, , 70, , 71, , 72, , 73, , 74, , 302, , 305, ,
307, , 308, , 309, , 311, , 319, , 320, , 322, , 323, , 330, , 331, , 333, ,
335, , 336, , 342, , 429, , 461, , 474, , 479, , 493, , 497, , 501
Middle cerebral artery (MCA), 19, , 80, , 457, , 546, , 547, , 549, , 556,
, 559, , 568–575. See also Intracranial arteries.
anterior temporal branch, 580
AP DSA, 571
bifurcation, 569, , 571, , 572, , 573, , 574
CTA, 574, , 575
3D-VRT CTA, 573
embryology, 568
graphics, 569
lateral DSA, 570
lateral (sylvian) fissure, 362
3T MRA, 572
right, 559
sheath of pial-like cells around, 19
sylvian fissure, 363, , 367
trifurcation, 572
Middle cerebral artery genu, 118
Middle cerebral peduncle, 457
Middle cranial fossa, 6, , 375, , 376, , 390
Middle deep temporal artery, 540
Middle frontal gyrus, 29, , 30, , 35, , 36, , 42, , 43, , 158, , 203, , 205
Middle internal frontal arteries, 562
Middle meningeal artery, 374, , 379, , 426, , 535, , 539, , 540, , 551, ,
565
foramen spinosum, 381, , 470
groove, 9
passing through foramen spinosum, 540
Middle nasal turbinate, 438
Middle occipital gyrus, 44, , 45, , 182
Middle portion (medial and lateral) of superior frontal gyrus, 158
Middle scalene muscle, 837, , 839, , 840, , 841
Middle temporal gyrus (area 21), 29, , 30, , 36, , 42, , 44, , 45, , 47, ,
48, , 49, , 142, , 152, , 160, , 161, , 166, , 167, , 168, , 191, , 193, ,
239, , 270, , 271, , 272, , 273
Midinternal auditory canal, 342
facial nerve, 491
Midline vermis, 334
Modiolus, 339, , 342, , 495
Moral judgment, subgenual cingulate cortex, 206
Motor, 53
Motor area, 276
Motor cortex, hand region, 278
Motor fibers, 502, , 508
Motor nerve, to stylopharyngeus muscle, 505
Motor nucleus
facial nerve, 484, , 485
trigeminal nerve, 464, , 465, , 469
Multifidus muscle, 704, , 705, , 706, , 707, , 708, , 709, , 769, , 774
Multimodal sensory cortex, 230
Multimodal sensory integration, orbitofrontal cortex, 170
Muscular artery, 814
Muscular branches, 591, , 813, , 814, , 819, , 820
dorsal, 818
occipital artery, 536, , 537
Musculocutaneous nerve, 835, , 836, , 858
Myelinated white matter, 61
Mylohyoid muscle, 467, , 475
Mylohyoid nerve, 467
N
Nasal bone, 5, , 8, , 380, , 381, , 386, , 388, , 393, , 398, , 399
Nasal branches, sphenopalatine artery, 541
Nasal capsule, cartilage of developing, 388
Nasal cartilage, 388
Nasal cavity, 409, , 473
root, 426
Nasal conchae, septal blush, 540
Nasal epithelium, 434
Nasal septum, 436, , 438
Nasociliary nerve, 442
Nasofrontal suture, 8
Nasopharyngeal adenoidal tissue, 119, , 123
Nasopharyngeal airway, 406, , 472
Nasopharyngeal carotid space, 417, , 420, , 504
Nasopharyngeal internal carotid artery, 428
Nasopharyngeal mucosal space, adenoids, 406
Nasopharynx, 113, , 120
Navigation, retrosplenial cingulate cortex, 212
Neck veins, 642
Nerve root, 742
Nerve root sleeve, 808, , 809
Nerve rootlets, 738
Nerve segments, left visual field, 449
Nerves, 654
Neural arch, 663, , 666, , 667, , 668, , 669, , 671, , 672, , 673
ossification, 662
Neural foramen, 655, , 669, , 670, , 682, , 684, , 685, , 686, , 687, ,
690, , 691, , 693, , 694, , 695, , 697, , 699, , 700, , 701, , 703, , 719, ,
729, , 730, , 731, , 736, , 737, , 739, , 743, , 745, , 746, , 747, , 749, ,
750, , 751, , 752, , 753, , 754, , 756, , 757, , 758, , 764, , 766, , 767, ,
769, , 770, , 774, , 794, , 803, , 817, , 821, , 823
lateral aspect, 690
venous plexus, 825, , 827
Neurocentral synchondrosis, 664, , 667, , 669, , 670, , 671, , 672
fused, 669
Neurodegenerative diseases, locus coeruleus, 95
Neurohypophyseal “bright spot, ”, 123
Neurohypophysis (NH), 298. See also Cavernous sinus;
Pituitary gland; Sella.
Neuropeptide system, 260–261
Neurosurgery, temporal pole, 230
Neurotransmitter systems, 260–263
distribution of key, 262
dopaminergic outputs and DaTscan, 263
minor, 260
Nodulus, 305, , 331, , 333, , 334, , 337
of vermis, 307
Nonossified epiphyses, 675
Norepinephrine, 260
Notochord course, 411
Nucleus accumbens, 206, , 262, , 263
Nucleus ambiguus, 327, , 425, , 503, , 505, , 509, , 510, , 517, , 518
Nucleus basalis, 98, , 262
Nucleus basalis of Meynert (NB), 94
Nucleus gracilis, 791
Nucleus of Perlia, 450
Nucleus pulposus, 679, , 690, , 691, , 693, , 696, , 697, , 702, , 762
O
Obex, 347, , 348, , 791
Oblique capitis inferior muscle, 704, , 724
Oblique capitis superior muscle, 704
Obturator internus muscle, 854
Obturator nerve, 778, , 845, , 851
Occipital, 53
Occipital artery, 534, , 535, , 536, , 537, , 539, , 592
Occipital bone, 4, , 6, , 7, , 9, , 373, , 374, , 375, , 376, , 378, , 379, ,
416, , 710
basilar portion (clivus), 417
condylar (lateral) portion, 416, , 417
jugular tubercle, 416
squamous part, 415, , 416
Occipital condyle, 374, , 378, , 379, , 417, , 418, , 421, , 524, , 525, ,
650, , 668, , 689, , 699, , 719, , 720, , 723, , 724, , 726, , 731, , 738, ,
740, , 741, , 815, , 826
Occipital cortex, 214
Occipital emissary vein, 609, , 610, , 611
Occipital forceps, 51, , 52
Occipital gyrus, 42
Occipital horn, 105, , 346, , 350, , 351, , 356, , 628
of lateral ventricle, 109, , 110
Occipital lobe, 42, , 182, , 448
brain, 28, , 29, , 30, , 31, , 33, , 34, , 35, , 38
Occipital pole, 182
Occipital sinus, 599, , 606, , 607, , 615
Occipital sulcus, 42
Occipital vein, 644
Occipital white matter, 477
Occipitomastoid suture, 6, , 9, , 375, , 376, , 377, , 413, , 415, , 416
Occipitotemporal gyrus, 36, , 41, , 46
Occipitotemporal sulcus, 29, , 44, , 46, , 47, , 101, , 102
Oculomotor cistern, 452, , 453, , 456
Oculomotor division of CNV, 382
Oculomotor nerve (CNIII), 113, , 114, , 116, , 119, , 120, , 122, , 303, ,
310, , 313, , 316, , 317, , 323, , 325, , 364, , 365, , 366, , 382, , 387, ,
407, , 422, , 423, , 424, , 425, , 445, , 446, , 450–457, , 459, , 461, ,
466, , 471, , 472, , 473, , 481, , 483, , 559, , 577, , 608
3T axial T2 and T1 MR, 454
3T axial T2 MR, 453
cistern, 113, , 317
clinical correlation, 457
enlarged and enhancing, 457
graphics, 452
interpeduncular cistern, 357, , 364, , 369
nuclei, 312
nucleus area, 315, , 453
orbit, 452
posterior cavernous, 367
Oculomotor nerve rootlets, 455
Oculomotor nuclear complex (ONC), 450
Oculomotor nucleus, 306, , 308, , 313, , 317, , 452
Odontoid, 718, , 720, , 824
Odontoid apex, 663
Odontoid ligaments, 710
Odontoid process, 418, , 663, , 666, , 668, , 711, , 713, , 717, , 718, ,
719, , 722, , 724, , 726, , 727, , 731, , 816, , 826
base, 722, , 724, , 725, , 727
lateral margin, 723
Odontoid synchondrosis, fused, 666
Odontoid tip, 720, , 722, , 725, , 726, , 727
Olfaction, parahippocampal gyrus, 218
Olfactory bulbs, 101, , 386, , 387, , 434, , 435, , 436, , 437, , 438
and tract, 294
Olfactory cortex, 434
Olfactory mucosa, 436, , 438
in olfactory recess, 391, , 393
Olfactory nerve (CNI), 386, , 422, , 423, , 434–439
bulb and tract, 423
clinical correlation, 439
coronal NECT, 436
3T coronal T1 MR and sagittal CT, 438
Olfactory recess, 396
with olfactory mucosa, 395
Olfactory sulcus, 29, , 33, , 36, , 46, , 435, , 437
Olfactory tract, 33, , 36, , 101, , 109, , 434, , 435, , 437
Olfactory trigone, 435
Olfactory tubercle, 296
Olivary eminence, 402
Olive, 326
Omohyoid muscle
anterior belly, 522
posterior belly, 522
Operculae, 28
Opercular (M3) middle cerebral artery segments, 568, , 569, , 571, ,
572, , 574, , 575
Ophthalmic artery (OA), 116, , 442, , 444, , 535, , 537, , 551, , 552, ,
554, , 555. See also Intracranial internal carotid artery.
and C6 internal carotid artery segment, 553, , 555
from internal carotid artery, 564, , 565
Ophthalmic division
entering superior orbital fissure, 467
frontal nerve branch, 465
trigeminal nerve, 114, , 382, , 423, , 464, , 465, , 466, , 473, , 608
Ophthalmic (C6) internal carotid artery segment, 550, , 551, , 556, ,
557
Ophthalmic nerve, 120, , 401
Opisthion, 711, , 718, , 720, , 723, , 724, , 725, , 739, , 740, , 815
Optic canal, 5, , 373, , 375, , 376, , 379, , 383, , 389, , 392, , 400, , 401,
, 403, , 423, , 556
with ophthalmic artery, 556
with optic nerve and ophthalmic artery, 387
Optic chiasm, 116, , 117, , 118, , 119, , 120, , 121, , 123, , 282, , 355, ,
367, , 440, , 441, , 443, , 446, , 448, , 449, , 456, , 471
Optic nerve (CNII), 114, , 120, , 121, , 122, , 282, , 325, , 367, , 381, ,
382, , 383, , 386, , 401, , 423, , 424, , 437, , 440–449, , 559, , 563
3T axial and sagittal T1 MR, 447
3T axial stir MR, 443
3T diffusion tractography, 449
dural sheath, 442
entering optic canal, 114, , 122
intracanalicular segment, 440, , 441, , 443
intracranial segment, 440, , 441, , 442, , 443, , 446
intraorbital segment, 440, , 441, , 442, , 443, , 447
left, 449
3T MP2RAGE MR, 448
in optic canals, 116
right, 449
Optic nerve canal, 385, , 387
Optic radiation, 55, , 283, , 441, , 449
Optic recess, 347, , 456
of 3rd ventricle, 114
Optic strut, 375, , 387, , 392
base, 376
Optic tract, 75, , 109, , 113, , 282, , 317, , 354, , 357, , 365, , 366, , 441,
, 443, , 445, , 454, , 456, , 460, , 483, , 559
area, 17, 92
right, 355, , 366
Orbit, 389
Orbital apex, 391
tumor, 457
Orbital branch, 467
Orbital fissure
inferior, 404
superior, 404
Orbital frontal, 49
Orbital frontal gyrus/sulci, 48
Orbital gyri, 29, , 42, , 44, , 46, , 437, , 438
of frontal lobe, 387
Orbital mucosal blush, 540
Orbital roof, 375, , 387, , 389, , 393, , 395
Orbital segment, oculomotor nerve, 452
Orbital sulci, 29, , 44, , 46
Orbital veins, 642
Orbitofrontal (lateral frontobasal) artery, 562, , 563, , 564, , 565, ,
567, , 568, , 569, , 570
Orbitofrontal cortex (area 11), 146, , 158, , 170–175, , 176, , 206, ,
212, , 230, , 288, , 289, , 298, , 299, , 448
coactivation, 171
location, 171, , 175
Orbitosphenoid, 402
Organ of Corti, 339, , 495
Oropharynx mucosal blush, 540
Ossification, 662–677
axial & sagittal bone CT, cervical (C3-C6) vertebra, 669
axial bone CT
atlas (C1) vertebra, 666
axis (C2) vertebra, 667
C7 vertebra, 670
lumbar vertebra, 672
sacrum, 673
thoracic vertebra, 671
coronal bone CT, axis (C2) vertebra, 668
sagittal bone CT, coccyx, 674
sagittal T1 MR, 676
sagittal T2 MR, 677
Ossified disc centrums, with red marrow, 675
Otic ganglion, 467, , 475
Outer (periosteal) dural layer, 12
Outer pial layer, 19
Outer table of calvarium, 7
Oval window, 488, , 489
P
“Pachymeninges, ”, 10
Pain perception, anterior cingulate cortex, 200
Paired bones, SB, 372
Paired foramina of Luschka, 347
Paired internal cerebral veins, 15
Paired posterior lateral joints, 696
Palatal mucosal blush, 540
Palatine bone, 374
horizontal plate, 379
Palatine nerves, greater and lesser, 401
Palatine process
maxilla, 379
maxillary bone, 380
Palatoglossus muscle, 522
Palmar muscular branches, 858
Papez circuit, 212
Paracentral artery, 562
Paracentral lobule, 48, , 49
Parahippocampal cortex (areas 28, 34, 35, and 36), 212, , 288, , 294,
, 297
Parahippocampal gyrus (areas 28, 34, 35, 36), 29, , 30, , 33, , 36, , 37,
, 38, , 41, , 42, , 47, , 48, , 49, , 101, , 102, , 103, , 104, , 105, , 106, ,
108, , 109, , 110, , 152, , 218–223, , 294, , 435
coactivation, 219
connectivity to, 222
areas 28 and 34, 221
bilateral area, 36, 220
subregions, 223
Parahippocampus, 108
Paraspinal muscle, 704–709
axial CECT
cervical, 706
lumbar, 708
thoracic, 707
coronal CECT, thoracolumbar, 709
Parasubiculum, 103
Parasympathetic fibers, 502
Paraterminal gyrus, 98, , 99, , 101
Parathyroid gland, 511
Paratracheal node, 511
Paresthesias, primary somatosensory cortex (areas 1, 2, 3), 128
Parietal bone, 4, , 5, , 6, , 7, , 8, , 9, , 373, , 374
Parietal branches, posterior cerebral artery, 584
Parietal foramina, 9
Parietal gyrus, 42
Parietal hubs, 266
Parietal lobe, 42, , 53
brain, 28, , 32, , 37, , 38
Parietal sulcus, 42
Parietomastoid suture, 8
Parietooccipital artery, 547, , 577, , 578, , 579, , 581, , 582, , 583, ,
585, , 592, , 594
Parietooccipital fissure, 43
Parietooccipital sulcus, 30, , 34, , 35, , 39, , 43, , 45, , 359, , 363
Parietooccipital vascular “blush, ”, 579
Parinaud syndrome, pineal region, 124
Parkinson disease
primary motor cortex, 134
subthalamus, 78
Parotid gland, 475, , 490
Parotid space, 374
Pars compacta, 94, , 96
Pars distalis, 114
Pars interarticularis, 683, , 685, , 688, , 689, , 696, , 697, , 698, , 701, ,
703, , 722, , 729, , 746, , 761, , 762, , 763, , 764
Pars intermedia, 112, , 114
Pars marginalis, 30
Pars nervosa, 114, , 412, , 413, , 414, , 415, , 426, , 512
jugular foramen, 376, , 503, , 506, , 519
Pars opercularis, 48, , 49
Pars orbitalis, 48, , 49
Pars reticulata, 94, , 96
Pars triangularis, 48, , 49
Pars tuberalis, 114
Pars vascularis, 412, , 413, , 415, , 426, , 512
jugular foramen, 376, , 377, , 506, , 519
Partial agenesis of corpus callosum, 77
Parvocellular red nucleus (pcRN), 94
Pattern completion, 294
Pattern separation, 294
Pedicle, 655, , 658, , 659, , 679, , 680, , 681, , 682, , 683, , 684, , 685, ,
686, , 687, , 688, , 690, , 691, , 692, , 693, , 694, , 695, , 697, , 699, ,
700, , 701, , 703, , 707, , 721, , 729, , 730, , 745, , 747, , 749, , 750, ,
751, , 752, , 753, , 754, , 755, , 756, , 757, , 761, , 762, , 763, , 764, ,
765, , 766, , 767, , 769, , 770, , 775, , 794
Pelvic surface, 782
Penetrating arteries, from vertebral, anterior spinal arteries, 549
Penetrating branches
Penetrating cortical artery, 20
with pial sheath, 19
Perforating branches
Periaqueductal gray matter, 306, , 312, , 313, , 315, , 317, , 454
cerebral aqueduct, 350
Periaqueductal grey, 308
Pericallosal artery, 562, , 563, , 564, , 565, , 567
and branches, 632
pericallosal cistern, 369
Pericallosal cistern, 359
pericallosal artery, 369
Pericallosal pial plexus, 564, , 565, , 567
Pericranium, 4, , 5
Perineural venous plexus, 838, , 843
Perineurium, 856, , 859
Periosteum of orbit (periorbita), 441, , 442
Peripheral hearing loss, primary auditory and auditory association
cortex, 242–247
Peripheral nerve, 856–861
axial T1 and T2 FS MR, 861
coronal T1 and STIR MR, 860
division, 857
lateral cord, 857
lower trunk, 857
medial cord, 857
middle trunk, 857
posterior cord, 857
upper trunk, 857
Peripheral white matter, 796
Perirhinal/ectorhinal cortex, 218, , 294, , 297
Perirhinal region, 223
Perirolandic, 232
Perirolandic cortex, 245
Peritentorial cistern, 358
Perivascular spaces, 10, , 17, , 18, , 18–25, , 82, , 86, , 88, , 96
7T axial T2 MR, 21
basal ganglia, 23
centrum semiovale, 22, , 23
7T coronal and axial T2 MR, 24
dot-like, 21, , 24
enlarged, 19, , 21, , 24, , 25
extreme capsule, 22, , 23
forming status cribrosum, 24
in inferior basal ganglia, 25
lateral lenticulostriate arteries in anterior perforated substance,
22
along lenticulostriate arteries, 23, , 24
of lenticulostriate arteries, 84
midbrain, 21
along penetrating arteries, 25
along penetrating lenticulostriate artery, 22
3T sagittal T1, axial T2, axial flair MR, 25
subcortical white matter, 21, , 22, , 23
left temporal lobe, 22
subinsular region, 22
surrounding lateral lenticulostriate arteries, 21, , 22
Persistent craniopharyngeal canal, 400, , 411
Petroclinoid ligament, 452
Petroclinoid segment, 450
Petrooccipital fissure, 374, , 376, , 377, , 404, , 405, , 413, , 416, , 419,
, 420, , 426, , 506, , 512
Petrooccipital suture, 6
Petrosal vein, 602, , 603, , 629, , 637, , 639, , 641
tributaries, 637, , 638
Petrosal venous plexus, 638
Petrosquamosal suture, 8
Petrous apex, 6, , 340, , 375, , 376, , 404, , 415, , 506, , 512, , 519
Petrous apex marrow, 381, , 474
Petrous ICA, 537
Petrous internal auditory canal, vertical segment, 487
Petrous internal carotid artery, 119, , 536, , 645
vertical segment, 468
Petrous (C2) internal carotid artery segment, 550
horizontal, 551, , 552, , 553, , 554, , 555
vertical, 551, , 552, , 553, , 554, , 555
Petrous ridge, 373, , 379, , 401, , 402, , 404, , 413
Petrous segment, internal carotid artery, 115, , 538
Petrous temporal bone, 6
Phantom limb pain, primary motor cortex, 134
Phantom limb syndrome, primary somatosensory cortex
(areas 1, 2, 3), 128
Pharyngeal branches
vagus nerve, 508
Pharyngeal mucosal space/surface, 374
Pharyngeal plexus, 510
Pharyngotympanic groove, 374
Pharynx, sensory from, 505
Phrenic nerve, 833
Pia, 10, , 12, , 18–25, , 360, , 617, , 800
arachnoid, 804
7T axial T2 MR, 21
conus surface, 805
fenestrations in, 20
Pia mater, 12, , 802
Pial cells around vein, clumps of, 20
Pial coating of brain, 19
Pial-lined trabeculae, 360
Pillar of fornix, 294
Pillars of fornix, 34, , 574, , 600, , 626
Pineal apoplexy, pineal region, 124
Pineal body. See Pineal region.
Pineal gland, 124, , 125, , 126, , 127, , 357, , 601, , 629. See also Pineal
region.
connections, 124
margin, 127
Pineal recess, 347
of 3rd ventricle, 125, , 127
Pineal region, 124–127
Piriform area, 435
Piriform cortex, 296
Piriformis muscle, 778, , 781, , 851, , 852, , 853, , 854
Pituitary gland, 112–123, , 367, , 398, , 407, , 424, , 446, , 466, , 472
3T axial T1 C+ MR, 115–116
Pituitary infundibulum, 366, , 367, , 441, , 454, , 456, , 563
Pituitary stalk, 118
Planum sphenoidale, 373, , 375, , 379, , 382, , 383, , 384, , 386, , 387,
, 392, , 398, , 399, , 410, , 411, , 438
Platysma, 542
Pons, 33, , 44, , 65, , 66, , 68, , 69, , 70, , 71, , 72, , 73, , 74, , 110, , 123,
, 302, , 303, , 305, , 309, , 310, , 318–325, , 333, , 336, , 337, , 342, ,
357, , 421, , 429, , 453, , 455, , 469, , 470, , 482, , 483, , 498, , 525, ,
827
anterior belly, 343
7T axial T1 MR, 320–321
7T axial T2 MR, 322–323
Ponticulus posticus, 589
Pontine, midbrain perforating branches from basilar artery, 549
Pontine arteries, 310, , 325
Pontine crossing tract, 53, , 56, , 58, , 479
Pontine nuclei, 262
Pontine perforating branches, basilar artery, 588
Pontine sensory nucleus, 425
Pontine venous plexus, 13
Pontomedullary junction, 311, , 323, , 325, , 329, , 337, , 490, , 498
Porus acusticus, 340, , 342, , 343, , 413, , 415, , 419, , 429, , 496, , 498,
, 499
facial nerve, 491
posterior margin, 418
Porus trigeminus, 465, , 469, , 474
trigeminal nerve in, 470
Postcentral gyrus, 28, , 29, , 30, , 32, , 35, , 38, , 43, , 47, , 48, , 49, ,
130, , 131, , 277
Postcentral sulcus, 29, , 39, , 43
Postcentral sulcus (anterior parietal) artery, 568
Posterior annulus fibrosus, 691
Posterior arch, 663, , 712
Posterior atlantooccipital membrane, 710, , 711
Posterior auricular artery, 534, , 535, , 536, , 540
Posterior auricular vein, 644, , 647
Posterior body
corpus callosum, 41
cortical margin, 713
Posterior branch, middle meningeal artery, 540
Posterior cavernous internal carotid artery, 119
Posterior cerebral artery (PCA), 122, , 310, , 316, , 325, , 333, , 364, ,
457, , 459, , 460, , 461, , 466, , 483, , 546, , 547, , 549, , 552, , 558, ,
561, , 564, , 570, , 572, , 576–585, , 588, , 592, , 595, , 623, , 630, ,
631, , 632. See also Intracranial arteries.
ambient cistern, 350, , 362
anterior temporal branch, 580
AP CTA, 582
AP VA DSA, 579
axial CTA, 585
“fetal” origin of, 561
graphics, 577
lateral, AP ICA DSA, 580
lateral CTA, 583, , 584
lateral VA DSA, 578
left, 590, , 593, , 594
3T MRA, 581
posterior temporal branches, 581, , 582, , 584
right, 590, , 593, , 594
splenial branch, 563
Posterior cervical line, 710, , 717
Posterior cervical vein, 727
Posterior cingulate and precuneus, 265, , 266, , 298, , 299
Posterior cingulate cortex (areas 23, 31), 152, , 155, , 164, , 194–199,
, 196, , 198, , 212
coactivation, 195
connectivity to, 197, , 198, , 199
Posterior cingulate gyrus/sulci, 43, , 45, , 48, , 49
Posterior cingulate region, 167
Posterior circulation, 546
Posterior clinoid process, 373, , 375, , 400, , 413
Posterior commissure, 50, , 125, , 127, , 350. See also Pineal region.
Posterior communicating artery (PCoA), 453, , 456, , 547, , 551, ,
552, , 555, , 557, , 558, , 559, , 560, , 561, , 566, , 572, , 576, , 577, ,
578, , 581, , 583, , 592. See also Intracranial arteries.
aneurysm, 457
infundibulum, 566
left, 559, , 581, , 585, , 594
right, 559, , 581, , 594
Posterior condylar canal, 412
Posterior corona radiata, 57
Posterior cortex vertebral body, 751
Posterior cranial fossa, 6, , 375, , 376
Posterior cribriform plate, 390
Posterior crura of fornix, 352
Posterior digastric muscle, 706
Posterior dural margin, 694
Posterior element, 655
Posterior ethmoid air cells, 389, , 390, , 391, , 394
Posterior ethmoid nerves, 467
Posterior ethmoid sinus, 378, , 380, , 381
Posterior ethmoidal artery, 387
Posterior ethmoidal canal, 385, , 387
Posterior ethmoidal foramen, 385, , 390
medial, 386
Posterior ethmoidal sulcus, 385
Posterior external jugular vein, 650
Posterior fossa, 302
Posterior fossa veins, 636–641
3T axial T1 C+ MR, 640–641
AP DSA, 639
lateral DSA, 638
Posterior genu
cavernous (C4) internal carotid artery, 537, , 551, , 552, , 553, ,
554, , 555
facial nerve, 485, , 488
Posterior iliac spine, 708
Posterior inferior cerebellar artery (PICA), 310, , 320, , 361, , 507, ,
519, , 549, , 586, , 588, , 590, , 591, , 592, , 594, , 595. See also
Intracranial arteries.
anterior medullary segment, 592, , 593, , 594
branches, in great horizontal fissure of cerebellum, 592
caudal loop, 594
with choroidal branches, 588
hemispheric branches, 592
inferior hemispheric branches, 588
lateral medullary segment, 592
left, 593
posterior medullary segment, 592, , 593
right, 588
supratonsillar segment, 592
tonsillar (cranial loop), 594
Posterior inferior frontal and premotor cortex, 299
Posterior inferior insula, greatest connectivity to, 179
Posterior insula, 178
Posterior intercavernous sinus, 116
Posterior intercostal vessels, 757, , 758
Posterior internal frontal arteries, 562
Posterior lateral nasal branches, 541
Posterior limb, internal capsule, 31, , 34, , 40, , 56, , 59, , 61, , 62, ,
63, , 64, , 65, , 66, , 67, , 68, , 69, , 70, , 71, , 72, , 73, , 74, , 80, , 81, ,
82, , 83, , 86, , 87, , 90, , 91
Posterior longitudinal ligament, 654, , 678, , 679, , 684, , 689, , 690, ,
691, , 692, , 694, , 697, , 702, , 711, , 724, , 725, , 741, , 758, , 767, ,
787, , 801
complex, 702
Posterior margin foramen magnum (opisthion), 723
Posterior margin vertebral body, 685
Posterior median atlantoaxial joint, 711
Posterior meningeal artery, 588
Posterior mesencephalic vein, 638
Posterior middle temp, 249
Posterior neural arch, 664, , 665, , 666, , 670, , 671
Posterior parahippocampal cortex, 218, , 220
Posterior parahippocampal gyrus, 223
Posterior parietal artery, 568, , 570
Posterior perforated substance, 364
Posterior pituitary vascular “blush” (normal), 552
Posterior portion of fusiform gyrus, 182
Posterior precuneus, 194
Posterior (dorsal) ramus, 857
Posterior ring, of C1 vertebral body, 517
Posterior scalene muscle, 841
Posterior semicircular canal, 488, , 496
Posterior septal branches, sphenopalatine artery, 541
Posterior skull base (PSB), 372, , 401, , 412–421
coronal bone CT, 418–419
graphic and MR venogram, 414
Posterior spinal arteries (PSAs), 586, , 812, , 813, , 814
Posterior spinolaminar lines, 718
normal alignment, 717
Posterior superior insula, greatest connectivity to, 179
Posterior superior recesses, 349
Posterior superior temporal sulcus, 191, , 298, , 299
Posterior temporal, medial temporal arteries, 568
Posterior temporal arteries, 461, , 577, , 578, , 579, , 581, , 584
Posterior temporal lobe vascular “blush, ”, 579
Posterior thalamic radiation, 55, , 56, , 57, , 58
Posterior thalamoperforating arteries, 561, , 577, , 578, , 579, , 583, ,
588, , 592
Posterior tubercle, 729
transverse process, 736, , 737, , 743, , 745
Posterior vertebral body
cortex, 692
cortical margin, 681, , 682
Posterior vertebral line, 728, , 732
Postolivary sulcus, 304, , 327, , 328, , 428, , 507, , 513, , 519
Posttraumatic stress disorder
insula and parainsula areas, 176
Potential subdural space, contrast, 807
Prebiventral/prepyramidal (suboccipital) cerebellar fissures, 331, ,
334, , 337. See also Cerebellum.
Precentral (prerolandic) artery, 568, , 570
Precentral cerebellar vein (PCV), 601, , 613, , 628, , 632, , 636, , 637, ,
638
Precentral gyrus, 28, , 29, , 30, , 32, , 35, , 38, , 39, , 43, , 47, , 48, , 49,
, 137, , 138, , 216, , 234, , 277
Precentral sulcus, 43
Prechiasmatic sulcus, 384
Precommunicating (P1) posterior cerebral artery segment, 559, ,
560, , 576, , 577, , 579, , 581, , 582, , 585, , 594
Precuneus (area 5), 30, , 45, , 49, , 143, , 144, , 152, , 154, , 156, , 158,
, 166, , 167, , 168, , 174, , 191, , 238
Precuneus cortex, 216
Precuneus gyrus/sulci, 48
Prefrontal arteries, middle cerebral artery, 568, , 570
Prefrontal cortex, 53, , 92
Prefrontal hubs, 266
Preganglionic segment, 401, , 423
abducens nerve, 482
trigeminal nerve, 343, , 464, , 465, , 467, , 469, , 470, , 471, , 474
Pregenual anterior cingulate, 205, , 249
Pregenual region, 206
Premedullary cistern, 358
vertebral artery, 368
Premedullary (medullary) cistern, 359, , 361
Premotor area, 276
Premotor cortex (area 6), 53, , 92, , 146–151, , 152, , 158, , 176, , 182
coactivation, 147
functional connectivity to, 148, , 149
location, 147, , 150, , 151
Premotor cortex area, 274
Prenasal space, 388
Preolivary sulcus, 304, , 327, , 328, , 425, , 428, , 513, , 519, , 523
Prepontine cistern, 11, , 116, , 305, , 308, , 321, , 323, , 349, , 357, ,
358, , 359, , 360, , 365, , 368, , 369, , 453, , 456, , 469
abducens nerve, 483
basilar artery, 349, , 368
Prepyramidal/suboccipital fissure, 303, , 311
Presphenoid, 402, , 410
Presupplementary motor area, 146, , 191, , 293
Pretectal nucleus, 441, , 443
Prevertebral muscle, 704
Prevertebral soft tissues, 728, , 733, , 739, , 740, , 741
line, 732
Prevertebral space, 689
Primary auditory and auditory association cortex (areas 41, 42),
242–247
coactivation, 244
location, 246–247
Primary auditory cortex, 28
Primary (tentorial) cerebellar fissures, 331, , 334, , 337. See also
Cerebellum.
Primary motor area, 276
Primary motor cortex (area 4), 28, , 134–139, , 176, , 274, , 277, , 278
activation, 277
connectivity to, 137–138
right primary motor cortex, 136
location, 139
Primary (1°) ossification center, 662
centrum, 668
odontoid, 668
Primary sensorimotor cortex (areas 1, 2, 3, and 4), 146
Primary somatosensory cortex (areas 1, 2, 3), 28, , 128–133, , 176
associated conditions, 128
associated literature keywords (neuroSynth), 128
location, 133
Brodmann areas 1, 2, and 3, 132
Primary/tentorial fissure, 303, , 311
Primary visual and visual association cortex (areas 17, 18, 19), 182–
187
coactivation, 183
functional connectivity, 184, , 185
functional visual subregions, 187
subregions, 186
Primary visual cortex, 28, , 280, , 283
Proatlantal intersegmental artery, 595
Procedural memory, 294
Projection fibers, 50
brain, 28
Promontory, 777, , 787
Prosopagnosia, fusiform gyrus, 224–229
Proximal basilar artery (hypoplastic), 595
Proximal cervical nerves, brachial plexus, 838
Proximal ECA branch, 542
Proximal roots, 839
Proximal vagal neuropathy, vagus nerve, 508
PS fibers, 508
Pseudosubluxation, 710
Psoas major, 661
Psoas muscle, 684, , 685, , 704, , 705, , 708, , 766, , 767, , 769, , 770, ,
771, , 772, , 774, , 775, , 786, , 845, , 846, , 848, , 849
Psychiatry, anterior cingulate cortex, 200
Pterion, 4, , 5, , 8
Pterygoid muscle
lateral, 409
medial, 409
Pterygoid plates, 382, , 383
lateral, 406
medial, 406
Pterygoid process, sphenoid bone, 379, , 381
Pterygoid process marrow, 475
Pterygoid venous plexus, 602, , 609, , 610, , 619, , 625, , 642, , 643, ,
645, , 647, , 648, , 650, , 651
Pterygomaxillary fissure, 378, , 392, , 404, , 405
Pterygopalatine fossa, 378, , 381, , 392, , 404, , 405, , 407, , 408, , 468,
, 475, , 535, , 536
cephalad aspect, 474
Pterygopalatine ganglion, 401, , 467
Pudendal nerve, 778, , 845, , 850, , 851
Pulmonary apex, 837
Pulvinar, thalamus, 41, , 78, , 82, , 85, , 86, , 87, , 363
Putamen, 34, , 36, , 40, , 41, , 44, , 73, , 74, , 78, , 79, , 80, , 81, , 82, ,
83, , 84, , 85, , 86, , 87, , 88, , 89, , 90, , 91, , 96, , 98, , 109, , 146, ,
263, , 315
Pyramid, 326, , 331, , 337, , 428
Pyramidal decussation, 303
Pyramidal eminence, 486, , 487, , 488
Pyriformis muscle, 785
Q
Q
Quadratus lumborum muscle, 705, , 708, , 845
Quadrigeminal cistern, 11, , 127, , 350, , 358, , 359, , 360, , 362, , 363,
, 368
Quadrigeminal plate, 31, , 312, , 337
cistern, 31, , 303, , 314, , 317, , 334, , 337, , 368, , 460, , 582
Quadrigeminal (P3) posterior cerebral artery segment, 576, , 577, ,
578, , 579, , 580, , 581, , 582, , 583, , 584
R
Radial nerve, 835, , 836, , 858
Radicular vein, 823
Radiculomedullary arteries, 812, , 814
anterior, 813
cervical, 820
dorsal, 814
posterior, 813
ventral, 814
Radius, 858
Ramus, 856
Ranawat measurement, 716
Raphe nuclei, 262
Receptive language, 290
Recesses, 346
Reciprocal connections, 212
Rectus capitis muscle, 704
Rectus muscle, superior, 452
Recurrent artery of Heubner (RAH), 562, , 565, , 567. See also
Intracranial arteries.
Recurrent laryngeal nerve (RLN), 508, , 511
left, 510
right, 510
Red nucleus (RN), 41, , 89, , 94, , 96, , 106, , 109, , 306, , 312, , 313, ,
315, , 317, , 335, , 452. See also Deep gray nuclei.
region, 315
Redlund-Johnell line, 714, , 716
Regulation, subgenual cingulate cortex, 206
Renal artery, 817
right, 817
Response inhibition, orbitofrontal cortex, 170
Restiform body, 326, , 327, , 330
Reticular formation, 312, , 326
Retina, 442
Retrobulbar fat, 447
Retrocondylar vein, 720, , 827
Retromandibular vein, 642, , 644, , 647, , 648, , 650, , 651, , 706
Retroolivary sulcus, 523
Retropulvinar cistern, 350
Retrosplenial cingulate, 248
Retrosplenial cingulate cortex (areas 29, 30), 152, , 212–217
cerebellar connectivity, 217
coactivation, 213
connectivity (rendered), 214, , 215
connectivity (slices), 216
Retrosplenial complex (RSC), 212
Retrosplenial cortex, 144
Reward, anterior cingulate cortex, 200
Rhomboid major muscle, 704
Rhomboid minor muscle, 704
Ribs, 682, , 687, , 700, , 709, , 750, , 751
1st, 658, , 659, , 661, , 733, , 735, , 738, , 740, , 741, , 750, , 829, ,
840, , 841
2nd, 738
5th, 750
12th, 658, , 750
costotransverse joint, 658
head, 700
left, 753
medial end, 661
medial portion, 698, , 751, , 752, , 753, , 755
neurovascular bundle inferior, 757
overlapping, right and left, 682
right, 753
Right anterior cerebral artery
A1 segment, 117, , 566, , 567, , 575
A2 segment, 118, , 566, , 567
pericallosal branch, 566
Right Brodmann area, 10, connectivity to, 167
Right carotid bulb, ICA, 538
Right cavernous internal carotid artery, 118
Right common carotid arteries (RCCA), 532, , 533, , 538. See also
Right internal carotid artery, 533, , 538, , 566
cervical segment, 538
Right middle cerebral artery, 117, , 566
Right orbitofrontal cortex, connectivity to, 173
Right petrous carotid artery, 118
Right posterior cerebral artery, 364
Right posterior inferior cerebellar artery, and inferior
hemispheric branches, 547
Right primary motor cortex, connectivity to, 136
Right subclavian arteries (RSCA), 531, , 532, , 533, , 587. See also
Right subgenual cingulate cortex, connectivity to, 209
Right superior cerebellar arteries, 364
Right supraclinoid internal carotid artery, 118
Right vertebral artery, 532, , 538, , 590, , 593
segment I, 815
segment II, 815
Right visual field, 285
Ring (annular) apophysis, 662
Rolandic (sensorimotor) cortex, 148, , 214
Root entry zone, trigeminal nerve, 465, , 467, , 469, , 470
lateral pons, 474
Rostral anterior cingulate gyrus/sulci, 48, , 49
Rostral middle frontal gyrus/sulci, 48, , 49
Rostral rib head, superior demifacet, 749
Rotatores muscle, 704, , 709
Round window niche, 488
S
S1, 778, , 795, , 851
body, 763, , 772, , 773, , 777, , 780, , 783, , 785, , 787
disc, 787
foramen, 783, , 785
with nerve, 787
nerve, 772, , 785, , 787
lumbosacral trunk, 781
nerve ganglion, 772
nerve roots, 768, , 780
root sleeve and nerve, 787
S2 disc, 785
sacral nerve, exiting ventral, 780
vertebral body, 762
S2, 778, , 851
body, 785
foramen, 783, , 785, , 787
nerve, 781, , 785, , 787
root sleeve and nerve, 787
ventral foramen with nerve and veins, 785
S3, 778, , 851
body, 785, , 787
foramen, 783, , 785
nerve, 785, , 787
root, 787
S4, foramen, 783
Sacral ala, 657, , 658, , 661, , 708, , 772, , 777, , 779, , 780, , 781, , 782,
, 783, , 785, , 787
Sacral articular process, 772
Sacral canal, 781, , 782, , 787
Sacral foramen, 661
Sacral hiatus, 674, , 779, , 783, , 787
Sacral nerve roots, 657
Sacral pelvic surface, transverse ridge, 779
Sacral plexus, 850–855
axial T1 MR and FS T2 MR, 855
coronal T1 MR, 852
lower band, 778, , 851
oblique axial T1 MR and FS T2 MR, 853–854
upper band, 778, , 851
Sacral promontory, 779, , 785
Sacral rudimentary disc, 787
Sacral spinal canal, 782
Sacrococcygeal joint, 776, , 777, , 787
Sacrococcygeal junction, 783, , 785, , 787
Sacroiliac joint, 661, , 673, , 708, , 763, , 772, , 773, , 776, , 777, , 779,
, 780, , 782, , 783, , 785, , 787
epiphyseal plate, 665
synovial component, 781
synovial portion, 782
Sacrum (S1-S5), 655, , 656, , 659, , 662, , 674, , 678, , 776–787
anterior radiograph & coronal NECT, 783
axial bone CT, 673
axial NECT, 782
axial T2 MR, 780–781
body, 777
coronal T1 MR, 784–785
3D-VRT NECT, 779
graphics, 777–778
lateral radiograph & sagittal T2 MR, 787
median crest, 777
pelvic surface, 777, , 780, , 787
sacral canal, 777
Sagittal suture, 7, , 8, , 9
Salience detection, anterior cingulate cortex, 200
Salience network, 258, , 268
Scala media, 339, , 495
Scala tympani, 339, , 495
Scala vestibuli, 339, , 495
Scalene muscle, 704, , 838
anterior, 705, , 706
middle, 705
Scalp, 4, , 16
Scalp, skull, and meninges
cranial meninges, 10–17
1.5T axial T1 C+ MR, 13–14
1.5T coronal T1 C+ MR, 15
pia and perivascular spaces, 18–25
7T axial T2 MR, 21
scalp and calvarial vault, 4–9
3D-VRT NECT, 8–9
axial NECT, 6
axial NECT and 3T sagittal T1 MR, 7
Scalp and calvarial vault, 4–9
axial NECT, 6
axial NECT and 3T sagittal T1 MR, 7
3D-VRT NECT, 8–9
Scalp veins, 605, , 615, , 642, , 648
Scapula, 660
Schizophrenia
Sciatic nerve, 657, , 778, , 781, , 845, , 850–855, , 861
axial T1 MR and FS T2 MR, 855
coronal T1 MR, 852
oblique axial T1 MR and FS T2 MR, 853–854
Sclera, 442, , 447
Scotty dog, 763
Scutum, 489
Sebaceous gland, 5
Secondary (2°) ossification center, 662
dens tip, 668
odontoid tip, 669
rib head, 671
Segmental arteries, 703, , 812, , 820
anterior, 813
dorsal branch, 814
posterior branch, 814
of T10, 813
and vein, 690, , 691
ventral branch, 813, , 814
Segmental feeding artery
intercostal, 817
lumbar, 818
Segmental ganglion, 695
Segmental lumbar artery, 762, , 772, , 773
Segmental lumbar vein, 762, , 771, , 772, , 773, , 775
Segmental nerve
within foramen, 690
within neural foramen, 691
sulcus, 697, , 698
Segmental vein, 703, , 823
Segmental vessels, 690
neural foramen with exiting root, 758
Self-referential cognition, posterior cingulate cortex, 194
Sella, 112–123, , 375, , 389
3T axial T1 C+ MR, 115–116
floor, 403
Sella turcica, 112, , 380, , 400, , 403, , 410, , 411
pituitary within, 411
Semantic dementia, temporal pole, 230
Semantic memory, 294
Semispinalis muscle, 704, , 705, , 706
Semispinalis thoracis muscle, 709
Sensorimotor cortex, 180, , 244
Sensorimotor network, 256, , 257, , 258, , 274–279
cerebellar motor regions, 279
functional activation, 278
motor overview, 276
somatosensory homunculus, 277
Sensorineural hearing loss (SNHL), vestibulocochlear nerve, 494
Sensory branch superior laryngeal nerve, 510
Sensory fibers, 502, , 508
Sensory loss, primary somatosensory cortex (areas 1, 2, 3), 128
Sensory nucleus, trigeminal nerve, 469
Septal vein, 599, , 600, , 601, , 604, , 609, , 614, , 622, , 623, , 624, ,
625, , 626, , 627, , 630, , 634, , 635
Septum pellucidum, 41, , 83, , 101, , 104, , 106, , 351, , 353, , 354, ,
355, , 629
Septum posticum, 800, , 802
Serotonin, 260
Serrated fibrous joints, 4
“Seven-up, coke down, ”, 338
Short arcuate fibers, 51, , 52
Short ciliary nerve, 467
Short-term, (working) memory, 294
Sigmoid plate, 415, , 506
Sigmoid sinus, 305, , 340, , 376, , 377, , 414, , 415, , 416, , 420, , 506, ,
512, , 599, , 602, , 605, , 606, , 607, , 609, , 611, , 612, , 615, , 618, ,
634, , 640, , 648, , 649, , 827
groove, 412
junction, 612
Singular canal, 340, , 496
Singular nerve, 339, , 495
Sinus confluence (torcular Herophili), 13, , 16, , 414, , 599, , 605, ,
634, , 641
Sinus tympani, 486, , 487, , 488
Skin, 4, , 6, , 7
Skull, 4
Skull base (SB)
axial CT, 375–378
3T axial T1 MR, 381
bones, 372
coronal CT and 3T T1 MR, 383
3D-VRT CT, 379
graphics, 373–374
3T T1 MR, 382
overview, 372–383
regions, 372
sagittal CT and 3T T1 MR, 380
surfaces, 372
Skull base segment
vagus nerve, 508
Social anxiety disorder, insula and parainsula areas, 176
Social attachment, subgenual cingulate cortex, 206
Social cognition, 188
Social network, 298–299
Soft palate, sensory from, 505
Solitary tract nucleus, 425, , 484, , 485, , 503, , 505, , 509, , 510
CNX, 327
Somatosensory association cortex, 144
Somatosensory cortex, 277
area, 278
Somatosensory/motor attention, 271
Spasticity, primary motor cortex, 134
Spatial navigation, parahippocampal gyrus, 218
Spatial navigation impairment (retrosplenial amnesia), retrosplenial
cingulate cortex, 212
Specific phobia, insula and parainsula areas, 176
Sphenoid bone, 120, , 374, , 384, , 388, , 410, , 417
body, 378, , 398, , 399, , 403, , 406, , 408
greater wing, 373, , 376, , 377, , 378, , 382, , 383, , 389, , 390, , 401, ,
403, , 406, , 407, , 409
lesser wing, 373, , 375, , 379, , 384, , 386, , 387, , 392, , 401
pterygoid process, 408
Sphenoid sinus, 6, , 113, , 115, , 120, , 123, , 375, , 376, , 377, , 381, ,
382, , 383, , 386, , 389, , 390, , 391, , 392, , 394, , 398, , 399, , 403, ,
404, , 405, , 407, , 410, , 424, , 466, , 468, , 470, , 473, , 474, , 523
extensive pneumatization, 400
Sphenoid sinus ostium, 391
Sphenooccipital synchondrosis, 377, , 378, , 391, , 398, , 399, , 402, ,
404, , 405, , 410, , 411, , 415, , 416, , 468, , 506, , 512, , 523, , 669
Sphenopalatine artery, 535, , 540, , 541
Sphenopalatine foramen, 378, , 392, , 405
Sphenoparietal sinus (SPS), 599, , 603, , 606, , 607, , 609, , 612, , 613,
, 616, , 619, , 620, , 625, , 641
Sphenosquamosal suture, 6
Spinal arterial supply, 812–821
AP DSA, 820
AP IA-DSA, 819
axial CT angiogram, 818
CT angiography, 817
DSA and CTA, 821
3D-VRT CECT, 815, , 816
Spinal artery, anterior, 813
Spinal canal, 659, , 680, , 684, , 707, , 721, , 749, , 751, , 752, , 753, ,
754, , 755, , 756, , 766, , 769, , 794, , 817
with thecal sac, 684, , 685
Spinal cord, 689, , 693, , 702, , 736, , 739, , 740, , 741, , 742, , 743, ,
744, , 745, , 747, , 757, , 758, , 759, , 790–799, , 793, , 798, , 801, ,
802, , 804, , 808, , 809, , 823, , 843
anterior median vein, 823
canal, 794
within canal, 751
central gray matter, 746
circulation, 812
dorsal coronal venous plexus, 823
thoracic, 702
upper thoracic, 794
Spinal ganglion, 745, , 747
Spinal nerve
dorsal root, 793
exiting, groove, 729, , 731
ventral root, 793
Spinal nerve roots, exiting, 730
Spinal nucleus, 425
accessory nerve (CNXI), 517, , 518
trigeminal nerve, 327, , 464, , 465, , 503, , 505, , 509, , 510
Spinal radicular artery, 591
Spinal rami, 591
Spinal root of CNXI, 517
Spinal rootlets of CNXI, 517
Spinal veins, 822–829
axial, sagittal, & coronal CECT MIP, 828
axial & sagittal CECT MIP, 829
axial T1 C+ MR, 824, , 825
coronal T1 C+ MR, 826, , 827
Spinalis thoracis muscle, 707, , 709
Spine, cord, meninges, and spaces
meninges and compartments, 800–809
spinal cord and cauda equina, 790–799
Spine, plexi and peripheral nerves
brachial plexus, 832
peripheral nerve and plexus overview, 856–861
sacral plexus and sciatic nerve, 850–855
Spine, vascular
spinal arterial supply, 812–821
spinal veins and venous plexus, 822–829
Spine, vertebral column, discs, and paraspinal muscle
cervical spine, 728–747
craniocervical junction, 710–727
intervertebral disc and facet joints, 696–703
lumbar spine, 760–775
paraspinal muscle, 704–709
sacrum and coccyx, 776–787
thoracic spine, 748–759
Spinolaminar line, 728, , 732
corticated margin, 733
Spinothalamic tract, 312
Spinous process, 656, , 667, , 669, , 679, , 680, , 681, , 682, , 683, ,
684, , 685, , 686, , 687, , 688, , 690, , 691, , 692, , 693, , 695, , 698, ,
699, , 700, , 701, , 705, , 708, , 709, , 717, , 721, , 729, , 736, , 737, ,
739, , 744, , 746, , 747, , 749, , 750, , 751, , 752, , 753, , 754, , 755, ,
756, , 757, , 758, , 761, , 763, , 764, , 765, , 766, , 767, , 768, , 769, ,
770, , 771, , 774, , 775, , 794
angulation, 728
bifid, 713
junction of lamina with, 694
sacrum, 660
thoracic spine, 658
Spiral ganglia, 339, , 495
distal axon form, 339
Splenial artery, 577, , 578, , 583
Splenial branch, 588
posterior cerebral artery, 576, , 583
Splenium, 77
corpus callosum, 30, , 34, , 35, , 37, , 39, , 40, , 83, , 105, , 107, , 352
Splenius capitis muscle, 704, , 705, , 706
Splenius cervicis muscle, 704, , 706
Splenius muscle, 706
Spondylolisthesis, 696
Spondylolysis, 696
Squamosal suture, 6, , 8
Squamous occipital bone, 9
Squamous temporal bone, 5, , 6, , 8, , 9
Stapedius muscle, 487
Stapedius nerve, 484, , 485
Sternocleidomastoid muscle, 705, , 706, , 837
Sternohyoid muscle, 522
Sternomastoid muscle, 542
CNXI motor branches to, 518
Sternothyroid muscle, 522
Straight gyrus, 29
Straight sinus (SS), 11, , 13, , 16, , 306, , 414, , 574, , 598, , 599, , 601,
, 603, , 605, , 606, , 607, , 609, , 611, , 613, , 614, , 615, , 619, , 621, ,
623, , 624, , 626, , 630, , 632, , 633, , 635, , 637, , 638
with falx cerebri, 607
junction, 628
Stratum orient, 103
Stratum radiatum, 104, , 106, , 107, , 108
Stratum radiatum lacunosum moleculare, 103
Striatum, 262, , 263, , 288
Stroke, primary motor cortex, 134
Styloglossus muscle, 522
Styloid process, 374, , 417, , 720
Stylomastoid foramen, 374, , 378, , 412, , 417, , 418, , 426, , 485, ,
487, , 488, , 490, , 524
fat, 485
temporal bone, 379
Stylopharyngeus branch, glossopharyngeal nerve, 502
Stylopharyngeus muscle, 505
Subaponeurotic areolar tissue, 5
Subaponeurotic tissue, 4
Subarachnoid spaces (SASs), 10, , 12, , 19, , 20, , 358–369, , 443, ,
444, , 636, , 758, , 775, , 801, , 802, , 803, , 804, , 807, , 808
artery, 20
3T axial T2 MR, 361–363
Subaxial spine, 728
Subcallosal area, 39, , 98, , 99, , 101, , 110
Subcallosal gyrus area, 435
Subclavian artery, 820, , 833, , 837, , 839, , 842
catheter, 820
left, 813, , 815
right, 815
Subclavian vein, 837, , 839, , 842
left, 829
right, 829
Subcortical connections, 152, , 158
Subcortical perivascular space, 23
Subcortical white matter, 59, , 65, , 66, , 68, , 69, , 70, , 71, , 72, , 73, ,
74
Subcutaneous fibroadipose layer, 7
Subcutaneous fibroadipose tissue, 5, , 6
Subcutaneous tissue, 4
Subdural space, 10, , 801, , 802
contrast, 807
Subependymal vein, 622, , 624, , 627, , 635
Subgenual cingulate cortex (area 25), 206–211, , 210
associated disorders, 206–211
cerebellar connectivity, 211
coactivation, 207
location, 207
Subgenual region, 206
Subiculum, 102, , 103, , 108, , 109, , 294, , 297
Sublingual space compartment, lingual nerve in, 475
Suboccipital muscle, 704
Suboccipital veins, 638
Suboccipital venous plexus, 414, , 605, , 615, , 639, , 640, , 645, , 647,
, 649
Subparietal sulcus, 43
Subpial space, 10, , 12, , 20
Substantia innominata, 95, , 98, , 99
Substantia nigra (SN), 41, , 86, , 89, , 92, , 94, , 96, , 106, , 109, , 263,
, 306, , 308, , 312, , 313, , 315, , 317, , 452
Subthalamic nucleus, 89, , 106. See also Deep gray nuclei.
Subthalamus, 78
Sulci (fissure), 28, , 42, , 43
exiting nerve, 686
Sulcus terminalis, 85
Superficial branch radial nerve, 858
Superficial cerebral veins, 616–621
AP DSA, 620
embryology, 616
lateral internal carotid artery DSA, 619
3T MRV, CTV, 621
Superficial cortical veins, 13, , 14, , 15, , 16, , 20, , 605, , 618, , 619, ,
620
unnamed, 609
Superficial middle cerebral vein (SMCV), 13, , 598, , 603, , 605, , 609,
, 610, , 611, , 613, , 616, , 617, , 618, , 619, , 620, , 621, , 625, , 641
Superficial (extrinsic or “immigrant”) muscles, 704
Superficial or external veins. See Superficial cerebral veins.
Superficial sagittal sinus, superficial (cortical) veins to, 599
Superficial temporal artery, 534, , 535, , 536, , 537, , 539, , 540, , 541,
, 644
groove, 8
Superficial white matter, 56
Superior alveolar artery, 535, , 536, , 540, , 541
Superior alveolar nerves, anterior and middle, 401
Superior annular epiphysis, 664
Superior articular facet, 679, , 681, , 684, , 712, , 713, , 729, , 736, ,
737, , 749, , 754, , 755, , 756, , 761, , 766
Superior articular process, 658, , 680, , 683, , 686, , 688, , 690, , 691, ,
693, , 694, , 695, , 697, , 698, , 699, , 700, , 701, , 703, , 729, , 747, ,
751, , 757, , 758, , 761, , 762, , 763, , 764, , 765, , 766, , 767, , 769, ,
770, , 775
Superior bony endplate, 679, , 749
Superior cerebellar arteries (SCAs), 321, , 325, , 333, , 453, , 455, ,
459, , 461, , 466, , 483, , 547, , 549, , 577, , 581, , 582, , 586, , 588, ,
590, , 592, , 593, , 594
left, 594
right, 594
superior hemispheric branches, 592
Superior cerebellar cistern, 127, , 303, , 331, , 337, , 358, , 359, , 360, ,
363, , 368, , 369
Superior (tentorial) cerebellar fissures, 330. See also Cerebellum.
Superior cerebellar hemisphere, 308, , 309, , 311, , 333, , 336
Superior cerebellar peduncle, 33, , 57, , 58, , 97, , 302, , 305, , 308, ,
314, , 316, , 319, , 321, , 330, , 331, , 333, , 335, , 349
decussation, 313, , 314
Superior cerebellar vermis, 44
Superior choroid veins, 638
Superior colliculus, 31, , 126, , 127, , 306, , 308, , 311, , 313, , 315, ,
441, , 443, , 454
Superior demifacet
for rib, 687, , 690
for rostral rib head, 679
Superior endplate, 681, , 682, , 688, , 690, , 691, , 694, , 700, , 701, ,
750, , 757, , 758, , 764, , 765
Superior extension cruciate ligament, 711
Superior frontal area, 143
Superior frontal gyrus, 29, , 30, , 34, , 35, , 36, , 42, , 43, , 46, , 48, ,
49, , 160, , 166, , 197, , 232, , 233, , 250, , 251
Superior frontal hubs, 266
Superior frontal sulcus, 29, , 43, , 46
Superior hemispheric branches (superior cerebellar artery), 588
Superior hypophyseal arteries, 551
Superior intercostal artery, 532
Superior internal parietal arteries, 562
Superior laryngeal nerve, 508, , 510
Superior longitudinal (arcuate) fasciculus, 50, , 51, , 52, , 56, , 57, ,
58
arcuate portion, 54
Superior longitudinal fasciculus white matter pathway, 268
Superior medullary velum, 306, , 311, , 313, , 314, , 319, , 331, , 337, ,
357, , 460
Superior mesenteric artery, 817
Superior nasal turbinate, 436
Superior nuchal line, 9
Superior oblique muscle, 442, , 444, , 447, , 459
Superior occipital gyrus, 43, , 182
Superior occipitofrontal fasciculus, 50, , 57
Superior ophthalmic vein, 13, , 442, , 444, , 447, , 603, , 619, , 642, ,
643
Superior orbital fissure, 5, , 116, , 373, , 376, , 377, , 382, , 383, , 385,
, 387, , 389, , 390, , 392, , 400, , 401, , 403, , 407, , 423, , 468, , 470
margin, 481
Superior parietal cortex (areas 5, 7), 49, , 140–145, , 146, , 158, , 220
associated literature keywords (NeuroSynth), 140
location, 145
Superior parietal gyrus/sulci, 48
Superior parietal lobule (areas 5 and 7), 29, , 35, , 92, , 176
Superior petrosal sinuses (SPS), 116, , 414, , 598, , 599, , 602, , 603, ,
606, , 607, , 612, , 619, , 621, , 624, , 639, , 641, , 643, , 646, , 649
Superior petrosal vein, 362
Superior prefrontal cortex (area 8), 155, , 158, , 266
coactivation, 153
connectivity to, 154, , 155, , 156
Superior pterygopalatine fossa, maxillary nerve, 474
Superior rectus muscle, 442, , 444, , 447
Superior sagittal sinus (SSS), 7, , 11, , 12, , 13, , 14, , 15, , 16, , 17, ,
39, , 414, , 567, , 598, , 599, , 605, , 606, , 607, , 609, , 610, , 611, ,
613, , 614, , 615, , 617, , 618, , 619, , 620, , 621, , 627, , 634, , 639
anterior aspect, 614, , 620
anterior end, 614
posterior aspect, 614, , 620
Superior salivatory nucleus, 484, , 485
Superior semicircular canal, 375, , 489, , 496, , 498, , 499
Superior (tentorial) surface, 336
Superior temporal gyrus and sulcus (area 22), 30, , 32, , 36, , 42, ,
44, , 45, , 47, , 48, , 49, , 152, , 158, , 182, , 191, , 193, , 212, , 232, ,
233, , 234, , 248, , 250, , 251, , 299
Superior thalamic radiation, 55
Superior thyroid artery, 531, , 534, , 535, , 536, , 537, , 539
Superior vena cava
cervical veins, 829
drainage, 827
Superior vermian artery, 588, , 592
Superior vermian cistern, 601
Superior vermian vein, 600, , 636, , 637, , 638, , 641
Superior vestibular nerve, 339, , 341, , 342, , 490, , 491, , 495, , 497, ,
499
Superior vestibular nucleus, 495
Superior visual field, 285
Supplementary area, 276
Supplementary motor area (area 6), 53, , 130, , 131, , 137, , 138, ,
146, , 146–151, , 148, , 149, , 176, , 180, , 182, , 274, , 276, , 290, ,
292, , 293
activation, 277
Supraclinoid internal carotid artery, 116, , 367, , 381, , 446, , 536, ,
537, , 547, , 553, , 561, , 563, , 569, , 577
“fetal” origin of posterior cerebral artery from, 580
right, 560
Supraclinoid left internal carotid artery, 119
Supramarginal/angular gyri, 270
Supramarginal gyrus (area 40), 30, , 34, , 35, , 45, , 48, , 49, , 146, ,
158, , 191, , 209
Supraorbital foramen, 5
Supraorbital nerve (branch of CNV1), 401, , 442, , 467
Supraorbital notch, 8, , 387
Suprapineal recess, 347
of 3rd ventricle, 125, , 126, , 127
Suprascapular artery, 531, , 533
Suprascapular branch, thyrocervical trunk, 532
Suprasellar cistern, 11, , 116, , 117, , 118, , 122, , 314, , 350, , 354, ,
355, , 358, , 359, , 360, , 362, , 365, , 366, , 367, , 368, , 369, , 446
Supraspinous ligament, 678, , 679, , 684, , 689, , 690, , 693, , 695, ,
756, , 757, , 758, , 768, , 774, , 775, , 780
Supratentorial brain anatomy
anterior cingulate cortex (areas 24, 32, 33), 200–205
cerebral hemispheres overview, 28–41
dorsolateral prefrontal cortex (areas 9, 46), 158–163
frontal pole (area 10), 164–169
fusiform gyrus (area 37), 224–229
bilateral, 227
coactivation, 225
connectivity, 226
probabilistic map, 228
gyral/sulcal, 42–49
inferior frontal gyrus (areas 44, 45, 47), 248–253
Brodmann areas, 252–253
inferior parietal lobule (areas 39, 40), 236–241
angular and supramarginal gyri, 240
functional connectivity, 238–239
location, 241
insula and parainsula areas (areas 13, 43), 176–181
orbitofrontal cortex (area 11), 170–175
parahippocampal gyrus (areas 28, 34, 35, 36), 218–223
posterior cingulate cortex (areas 23, 31), 194–199
premotor cortex and supplementary motor area (area 6), 146–151
primary auditory and auditory association cortex (areas 41, 42),
242–247
coactivation, 244
location, 246–247
primary visual and visual association cortex (areas 17, 18, 19),
182–187
retrosplenial cingulate cortex (areas 29, 30), 212–217
subgenual cingulate cortex (area 25), 206–211
superior prefrontal cortex (area 8), 152–157
temporal cortex (areas 20, 21, 22), 188–193
temporal pole (area 38), 230–235
bilateral, 234
left, 233
location, 235
right, 232
white matter tract, 50–77
Supratentorial cistern, 358
Supratonsillar segment, 588
Sweat gland and duct, 5
Sylvian (lateral cerebral) fissure, 17, , 31, , 34, , 36, , 37, , 38, , 47, ,
358, , 363, , 366, , 569. See also Middle cerebral artery.
M1 segment, 367
Sympathetic chain, 511
Sympathetic ganglion, 857
Synchondrosis, 662, , 666, , 667, , 669, , 671, , 672, , 673
fused, 673
T
T1, 841
pedicle, 740
root exiting, 731
transverse process, 733, , 738, , 840
ventral ramus, 835, , 836, , 843
vertebrae, 839
vertebral body, 750
T5
body, 750
pedicle, 750
T6
neural foramen, 759
T6-T7 disc, 759
T7
inferior articular process, 759
lamina, 759
neural foramen, 759
pedicle, 759
rib, 752, , 759
superior demifacet, 752
superior endplate, 702, , 759
T8
body, lateral cortical margin, 750
vertebral body, 702
T9, transverse process, 750
T10, superior endplate, 750
T12
pedicle, 817
rib, 762, , 763
vertebral body, 750
T12 root, exiting at T12-L1 level, 657
Tail
of caudate nucleus, 82, , 83, , 101, , 105
of hippocampus, 105
Tapetum, 56, , 57, , 58
Taste fibers, 502
Tectal plate, with superior, inferior colliculi, 125
Tectorial membrane, 689, , 710, , 711, , 723, , 724, , 725
Tectum (quadrigeminal plate), 127, , 262, , 311, , 312, , 313
Tegmen tympani, 419, , 488, , 489
Tegmentum, 312, , 313
Tela choroidea, 346
Temperature perception, anterior cingulate cortex, 200
Temporal bone, 4, , 373, , 374, , 377, , 515
mastoid, 376
petrous ridge, 412
squamous portion, 375
Temporal cortex (areas 20, 21, 22), 176, , 188–193
Brodmann areas 20, 21, and 22, 192
coactivation, 189
connectivity, 190, , 191
gyri and sulci, 193
location, 189
Temporal gyrus, 42
Temporal horn, 36, , 41, , 101, , 104, , 106, , 107, , 108, , 109, , 110, ,
346, , 347, , 349, , 350, , 353, , 354, , 355, , 356
lateral ventricle, 102, , 105, , 111, , 341
Temporal hubs, 266
Temporal lobe, 36, , 37, , 38, , 42, , 56, , 77, , 341, , 407, , 448, , 462, ,
463, , 476, , 477, , 478, , 479, , 491, , 493, , 499, , 501, , 526
brain, 28, , 31, , 33
white matter, 65, , 67, , 69, , 70, , 71, , 72, , 73, , 74
Temporal operculum, 38
Temporal pole (area 38), 48, , 49, , 230–235, , 299
bilateral, 234
left, 233
location, 235
right, 232
Temporal sulcus, 42
Temporal white matter, 63, , 64, , 66, , 68
Temporalis muscle, 6, , 7, , 467, , 475
Temporomandibular joint, 416
Temporooccipital artery, 568, , 570, , 572
Temporooccipital cortex, 131
Temporoparietal junction, 154, , 155, , 156, , 166, , 167, , 168, , 196, ,
197, , 198, , 238, , 265, , 266, , 298
Temporoparietal suture, 5
squamous, 8
Tensor tympani muscle, 487, , 489
belly, 487
Tensor tympani tendon, 489
Tensor veli palatini muscle, 475
Tentorial branch, meningohypophyseal trunk
cut off, 551
enlarged, 552
Tentorial incisura, 11
Tentorial segment, trochlear nerve, 458
Tentorial veins, 13, , 603, , 613, , 637, , 641
Tentorium, 309, , 311
apex of, 601
Tentorium cerebelli, 11, , 13, , 15, , 16, , 17, , 31, , 33, , 37, , 39, , 125,
, 323, , 335, , 336, , 425, , 593, , 600, , 628
with tentorial incisura, 607
with tentorial veins, 31, , 600
Terminal motor branches, 484
Terminal vein, 125, , 625, , 632
in striothalamic groove, 624, , 635
Thalamic nuclei, 79
Thalamic vein, 638
Thalamoperforating arteries, 549, , 582, , 592
Thalamostriate vein, 584, , 599, , 601, , 604, , 609, , 610, , 614, , 620, ,
622, , 623, , 624, , 625, , 626, , 627, , 630, , 634, , 635
Thalamus, 28, , 31, , 34, , 37, , 39, , 40, , 44, , 54, , 55, , 59, , 60, , 61, ,
62, , 63, , 64, , 65, , 66, , 67, , 68, , 69, , 70, , 71, , 72, , 73, , 74, , 78–
93, , 107, , 109, , 110, , 125, , 127, , 146, , 158, , 176, , 182, , 274, ,
315, , 351, , 443, , 448, , 624
axial CECT, 81
connectivity, 93
7T coronal T2-TSE MR, 88–89
input and output, 92
lateral geniculate nucleus of, 449
7T postmortem axial T1 MR, 90–91
pulvinar, 577
vascular supply, 78
Thecal sac, 694, , 695, , 766, , 770, , 771, , 772, , 773, , 774, , 776, ,
780, , 787, , 809, , 818
spinal cord, 820
termination, 787
Theory of mind, 152
Thick meninges, 10
Thin meninges, 10
3rd ventricle, 34, , 36, , 81, , 84, , 85, , 98, , 104, , 107, , 108, , 114, ,
623, , 624, , 629
Thoracic aorta, 814
Thoracic intervertebral discs, 657, , 661, , 754, , 755
Thoracic kyphosis, 748
Thoracic lamina, 660
Thoracic pedicle, 661
Thoracic ribs, 658
Thoracic segmental (intercostal) artery, 814
Thoracic spinal cord, 656, , 690, , 762
Thoracic spine, 748–759
axial bone CT, 754, , 755
axial T2 MR, 759
coronal CT myelogram, 751
3D-VRT NECT, 752, , 753
graphics, 749
radiography, 750
sagittal CT myelogram, 756
sagittal T1 MR, 757
sagittal T2 MR, 758
Thoracic spinous process, 659, , 660
Thoracic vertebra (T1-T2), 662
axial bone CT, 671
Thoracic vertebral body, 656, , 657, , 659, , 679, , 682, , 687, , 690, ,
749
with kyphosis, 655
lateral aspect, 690
Thoracolumbar fascia
anterior layer, 705, , 708
middle layer, 705, , 708
posterior layer, 705, , 708
Thoracolumbar junction, 748
Thyrocervical trunk, 531, , 532, , 533, , 539, , 820
branches, 821
right, 813, , 815
Thyroid blush, 820
Tinnitus, primary auditory and auditory association cortex, 242–
247
Tongue base, sensory from, 505
Tonsillar vein, 637, , 640
Tonsils, 331, , 334, , 335, , 336, , 337
Torcular Herophili, 414, , 606, , 607, , 609, , 613, , 615, , 620
Torus tubarius, 406, , 473
Trabeculae, in subarachnoid space, 12, , 17
Trachea, 757, , 758
Tracheal air column, 750
Tracheoesophageal groove, 511
Transethmoidal segment, 434
Transverse abdominis muscle, 708
Transverse facial artery, 536, , 540
Transverse foramen, 663, , 666, , 667, , 669, , 680, , 697, , 698, , 699, ,
712, , 720, , 721, , 727, , 729, , 737
left vertebral artery, 815
right vertebral artery, 815
vertebral artery, 692, , 706, , 741, , 742, , 743, , 745, , 746, , 747
Transverse ligament, 711, , 720, , 723, , 724, , 726, , 727, , 742
Transverse occipital sulcus, 46
Transverse pontine fibers, 306
Transverse process, 657, , 658, , 659, , 661, , 670, , 672, , 679, , 680, ,
681, , 682, , 683, , 684, , 685, , 686, , 687, , 688, , 693, , 698, , 699, ,
701, , 708, , 712, , 713, , 720, , 721, , 722, , 728, , 729, , 731, , 736, ,
743, , 745, , 746, , 747, , 749, , 751, , 752, , 753, , 754, , 755, , 761, ,
763, , 764, , 765, , 766, , 767, , 769, , 770, , 771, , 775
anterior tubercle, 680, , 686, , 692, , 697, , 698, , 712
left, 753
posterior tubercle, 686, , 692, , 698, , 712
right, 753
Transverse sinus (TS), 13, , 16, , 414, , 598, , 599, , 603, , 605, , 606, ,
607, , 612, , 613, , 615, , 618, , 634, , 637, , 641, , 827
junction, 612
left, 639
right, 610, , 615
Trapezius muscle, 704, , 705, , 706, , 707
CNXI motor branches to, 518
Trapezoid body, 319
Traumatic brain injury
orbitofrontal cortex, 170
primary motor cortex, 134
temporal pole, 230
Traumatic injury, frontal pole, 164
Trigeminal artery, persistent, 595
Trigeminal fascicles, 471
within Meckel cave, 117
Trigeminal ganglion, 114, , 319, , 387, , 401, , 407, , 452, , 465, , 467, ,
470, , 471, , 472, , 474
in floor of Meckel cave, 115
within Meckel cave, 113
Trigeminal (gasserian) ganglion, 117
Trigeminal groove, 376, , 468
Trigeminal nerve (CNV), 115, , 303, , 305, , 308, , 309, , 310, , 319, ,
321, , 323, , 324, , 325, , 362, , 422, , 452, , 455, , 461, , 463, , 464–
479, , 481, , 498
1st (ophthalmic or V1) division of, 113, , 120, , 608
2nd (maxillary or V2) division of, 113, , 608
3rd (mandibular or V3) division of, 113
axial bone CT, 468
3T axial T1 C+ MR, 470
3T axial T1 MR, 475
3T axial T2 MR, 469
cerebellopontine angle, 353
3T DTI, 479
graphics, 465–467
main sensory nucleus, 319
maxillary division, 409
Meckel cave, 325
fascicles, 355
mesencephalic nucleus, 319
motor nucleus, 319
3T MR, 477–478
nuclei, 318
preganglionic segment, 343, , 445
root entry zone, 319
3T sagittal T2 and axial T1 MR, 474
3T T2-space MR, 476
Trigeminothalamic tracts, 92
Trigonal segment, oculomotor nerve, 451
Trigone, olfactory nerve, 563
Trochlear division of CNV, 382
Trochlear nerve (CNIV), 113, , 114, , 120, , 303, , 313, , 316, , 382, ,
387, , 409, , 422, , 423, , 424, , 425, , 452, , 458–463, , 466, , 472, ,
473, , 481, , 608
3T axial T2 MR, 460
3T CISS MR, 462
nuclei, 312
3T T2-space MR, 463
Trochlear nucleus, 306, , 313, , 314, , 317, , 458, , 459
True synovial joint, 696
Tuber, 331, , 337
Tuber cinereum, 121, , 123, , 445
of hypothalamus, 113, , 114
Tuberculum sellae, 386, , 389, , 400, , 401, , 403
Tympanic annulus, 488, , 489
Tympanic branch (Jacobson nerve), glossopharyngeal nerve, 502
Tympanic membrane, 489
Tympanic segment, facial nerve, 485, , 488, , 489
U
“U” fibers, 56
Ulna, 858
Ulnar nerve, 835, , 836, , 857, , 858
Uncal recess of temporal horn, 40, , 104, , 109
Uncal sulcus, 108
Uncinate fasciculus, 50, , 52, , 54, , 55, , 57, , 58
Uncinate process, 681, , 686, , 692, , 697, , 699, , 719, , 729, , 734, ,
739
Uncomplicated unilateral sensorineural hearing loss (SNHL), 338
Uncovertebral joint, 681, , 686, , 728, , 729, , 743, , 744
Uncus, 29, , 30, , 33, , 40, , 44, , 101, , 104, , 108, , 109, , 294, , 435, ,
445, , 453, , 455, , 460
Unpaired bones, SB, 372
Upper cervical cord, 361
Upper clivus, 482, , 506, , 512
Upper motor neuron syndrome, primary motor cortex, 134
Uvula, 331, , 337
V
V1 (extraosseous) vertebral artery segment, 187, , 538. See also
Extraosseous (V1) segment vertebral artery segment.
V2 (foraminal) vertebral artery segment, 538. See also Foraminal
(V2) vertebral artery segment.
maxillary division, 423
V2/V3, 187
V3 segment. See also Extraspinal (V3) vertebral artery segment.
mandibular division, 423
V3 vertebral artery, 724
horizontal segment, 726, , 727, , 742
V4 vertebral artery segment, 726. See also Intradural (V4)
vertebral artery segment.
V5/MT, 187
Vagal nerve dysfunction, 508
Vagus nerve (CNX), 303, , 327, , 328, , 329, , 413, , 422, , 423, , 425, ,
428, , 503, , 504, , 507, , 508–515, , 517, , 518, , 521, , 527
approximate location in pars vascularis, 512
axial bone CT, 512
3T axial T2 MR, 513
branch to carotid branch of CNIX, 510
bulbar CNXI fibers cross to, 518
bulbar CNXI fibers transfer to, 517
3T coronal T2-space MR, 515
dorsal, 425
entering jugular foramen, 513
graphics
extracranial, 510–511
proximal CNX, 509
3T MR, 514
nuclei, 326
in pars vascularis, 521
to thorax and abdomen, 510
trunk, 511
Vallecula, 331, , 334, , 335
Valuation
reward, and adaptive behavior, orbitofrontal cortex, 170
subgenual cingulate cortex, 206
Vasculature, 654
Vein of Galen (VofG), 125, , 127, , 598, , 599, , 601, , 605, , 609, , 610,
, 611, , 613, , 615, , 616, , 617, , 621, , 622, , 623, , 624, , 625, , 626, ,
628, , 630, , 631, , 632, , 633, , 636, , 637, , 638, , 639, , 827
upper end, 614
Vein of Labbé (VofL), 414, , 599, , 605, , 609, , 611, , 615, , 616, , 618,
, 619, , 621, , 634, , 637, , 641
Vein of Trolard (VofT), 14, , 16, , 616, , 618, , 619, , 620, , 621, , 625, ,
627
left, 618
right, 618
Veins and venous sinuses
brain
dural sinuses, 606–615
intracranial venous system overview, 598–605
superficial cerebral veins, 616–621
deep cerebral veins, 622–635
extracranial veins, 642–651
3T axial T1 C+ MR, 647–648
coronal CECT, 646
sagittal CECT, 645
posterior fossa veins, 636–641
Velum interpositum, 11, , 126, , 358, , 607
cistern, 363
Venous channel, 766
Venous “lake, ”, 12
Venous plexus, 822–829, , 827
hypoglossal canal, 826, , 827
surrounding vertebral artery, 827
Venous sinus, 12
Venous sinus endothelium, 12
Ventral anterior cingulate, 203
Ventral attention network, 257, , 258, , 268
Ventral (anterior) brainstem, 59, , 60, , 63, , 64
Ventral cochlear nucleus, 495
CNVIII, 327
Ventral dural margin, 689, , 741
Ventral epidural plexus, 809
Ventral epidural space, 694
Ventral horn, 796
gray column, 517, , 791
Ventral intermediate nucleus, 92
Ventral medial nucleus of thalamus, 176
Ventral median fissure, 327, , 791, , 793, , 796
Ventral nerve root, 744, , 745, , 747, , 791, , 796, , 803, , 808
Ventral (anterior) pons, 67
Ventral posterior cingulate, 194
Ventral posterior inferior nucleus of thalamus, 176
Ventral premotor cortex, 146
Ventral rami/roots, 857
brachial plexus, 832, , 838
Ventral sacral foramina, 777, , 779, , 780, , 781, , 782, , 783
Ventral tegmental area (VTA), 94–95, , 96, , 158, , 263
Ventral tier nuclei, 92
Ventral white commissure, 791
Ventricles, 346–357
3T axial T2 MR, 348–351
4th, 303, , 305, , 308, , 311, , 316, , 319, , 320, , 321, , 323, , 326, ,
333, , 334, , 342, , 346, , 347, , 349, , 352, , 357, , 361, , 362, ,
460, , 462, , 463, , 469, , 490, , 497
apex, 350
choroid plexus, 329, , 331, , 334, , 335, , 357
fastigium, 352, , 357
inferior, 304, , 305, , 320, , 322, , 327, , 328, , 329, , 332, , 348
lateral recess, choroid plexus, 357
posterior superior recess, 352
roof, choroid plexus, 347
superior, 306, , 314, , 333
superior recess, 313, , 316
upper, 349
3rd, 315, , 324, , 325, , 346, , 347, , 350, , 353, , 354, , 360, , 363, ,
364, , 365, , 445, , 446, , 448, , 455, , 456
anterior, 363
choroid plexus, 368
infundibular recess, 347, , 350, , 355, , 357, , 362, , 366
optic recess, 366
optic (chiasmatic) recess, 347, , 357
pineal recess, 347
posterior, 363
roof, choroid plexus, 347, , 354
suprapineal recess, 347
Ventricular/choroidal branches, posterior cerebral artery, 576
Ventrolateral sulcus, 791
Ventrolateral thalamus, 60
Vermis, 37, , 333, , 334, , 349
central lobule, 334
cerebellar, 330
lobules, 330
nodule, 335
Vertebral arch, 728
Vertebral artery (VA), 304, , 307, , 309, , 310, , 320, , 325, , 328, , 332,
, 343, , 361, , 413, , 420, , 421, , 428, , 483, , 498, , 514, , 519, , 523, ,
526, , 539, , 546, , 586, , 651, , 689, , 692, , 699, , 705, , 706, , 723, ,
724, , 726, , 727, , 738, , 741, , 742, , 743, , 744, , 745, , 746, , 747, ,
793, , 824, , 825, , 827, , 837, , 838, , 843. See also Cervical carotid
arteries; Intracranial arteries.
above C1 ring, 533, , 538
ascends between C1, C2, 589
in C1 transverse foramen, 533, , 591
in C2 transverse foramen, 533
in cerebellomedullary cisterns, 361
course, 699
enters C2 transverse foramen, 591
exits C2 transverse foramen, 591
in hypoglossal canal, 525
hypoplastic, 595
left, 531, , 559, , 813, , 815, , 816
medullary cistern, 348
muscular branches, 591
90° lateral turn, 589
premedullary cistern, 364
right, 531, , 559, , 813, , 815, , 816, , 820
transverse foramen, 706, , 741, , 742, , 743, , 745, , 746, , 747
turns anteromedially to enter foramen magnum, 591
V2 segment, 703
venous plexus, 743
Vertebral artery flow void, 809
Vertebral body, 655, , 656, , 677, , 678, , 679, , 681, , 685, , 686, , 687,
, 688, , 694, , 698, , 700, , 705, , 708, , 729, , 754, , 755, , 756, , 757, ,
758, , 761, , 764, , 765, , 766, , 767, , 771, , 818, , 823
anterior cortex, 695
anterior cortical margin, 681, , 682, , 683, , 693, , 701, , 750, , 752
bony endplate, 699
branch, 821
centrum, 664
cervical, 697
complete, 676
cortex, 759
cortical bone, 684
cortical bony margin, 697
cortical margin, 691
endplate, 680, , 700, , 767, , 769
inferior cortical margin, 683
lateral aspect, 690
lateral cortical margin, 682, , 683, , 752, , 753
lateral margin, 700
and ligaments, 678–695
axial NECT, 684
cervical 3D-VRT NECT, 686
cervical axial T2* MR, 692
cervical radiography, 681
cervical sagittal T2 MR, 689
graphics, 679–680
lumbar 3D-VRT NECT, 688
lumbar axial T1 MR, 695
lumbar coronal NECT, 685
lumbar radiography, 683
lumbar sagittal T1 MR, 694
thoracic 3D-VRT NECT, 687
thoracic axial T2 MR, 693
thoracic radiography, 682
thoracic sagittal T2 MR, 690
medullary bone, 684
postcentral branch, 813, , 814
posterior cortical margin, 680, , 750
posterior margin, 730
superior cortical margin, 683
T8, 702
thoracic, 707
Vertebral bony endplate, 684, , 701
Vertebral canal, 712, , 729, , 737, , 761, , 766, , 767
Vertebral column, discs, and paraspinal muscle
vertebral body and ligaments, 678–695
axial NECT, 684
cervical 3D-VRT NECT, 686
cervical axial T2* MR, 692
cervical radiography, 681
cervical sagittal T2 MR, 689
graphics, 679–680
lumbar 3D-VRT NECT, 688
lumbar axial T1 MR, 695
lumbar coronal NECT, 685
lumbar radiography, 683
thoracic 3D-VRT NECT, 687
thoracic axial T2 MR, 693
thoracic radiography, 682
thoracic sagittal T2 MR, 690
vertebral column overview, 654–661
coronal NECT, 660–661
3D-VRT NECT, 658
3D-VRT NECT and sagittal CT, 659
sagittal T2 MR, 656
Vertebral column, discs, and paraspinal muscle, ossification, 662–
677
axial & sagittal bone CT, cervical (C3-C6) vertebra, 669
axial bone CT
atlas (C1) vertebra, 666
axis (C2) vertebra, 667
C7 vertebra, 670
lumbar vertebra, 672
sacrum, 673
thoracic vertebra, 671
coronal bone CT, axis (C2) vertebra, 668
graphics, 663–665, , 675
sagittal bone CT, coccyx, 674
sagittal T1 MR, 676
sagittal T2 MR, 677
Vertebral column overview, 654–661
coronal NECT, 660–661
3D-VRT NECT, 658
3D-VRT NECT and sagittal CT, 659
sagittal T2 MR, 656
Vertebral endplate, 679, , 688, , 749, , 754
Vertebral (neural) foramen, 749
Vertebral ossification center, 677
Vertebral veins, 651
surrounding vertebral artery, 650
Vertebral venous channels, 823
Vertebral venous plexus, 642, , 649, , 651
Vertebral venous system (VVS), 822
Vertebrobasilar confluence in premedullary cistern, 361
Vertebrobasilar junction, prepontine and medullary cistern
junction, 364
Vertebrobasilar system, 586–595
AP DSA, 593
DSA, 591
3D-VRT CTA, 589, , 590
embryology, 586
3D-VRT CTA, 587
lateral DSA, 592
3T MRA, 594
Vertical (A2) anterior cerebral artery segments, 559, , 560, , 562, ,
563, , 564, , 565, , 566, , 567, , 574, , 575
Vertical crest (Bill bar), 339
Vertical petrous internal carotid artery, 377, , 381
canal, 405, , 416
Vertical segment petrous internal carotid artery, 489, , 506, , 512
Vertical vertebral artery, between C1, C2, 533
Vesalius, foramen, 400
Vestibular apparatus, 492, , 493, , 500, , 501
Vestibular nerve, 463, , 492, , 493, , 494, , 500, , 501
Vestibular nuclear complex, 494
Vestibular nuclei, 425
inferior, 339
lateral, 339
medial, 339
superior, 339
Vestibule, 340, , 486, , 496, , 498, , 515, , 524, , 527
Vestibulocochlear nerve (CNVIII), 303, , 305, , 307, , 309, , 320, ,
327, , 329, , 338, , 339, , 341, , 342, , 343, , 413, , 422, , 423, , 424, ,
425, , 429, , 481, , 490, , 491, , 493, , 494–501, , 527
axial & coronal bone CT, 496
3T axial T2 MR, 497
3T MR, 501
nuclei, 318
3T oblique sagittal T2 MR, 499
origin, 322, , 329
3T T2-space MR, 500
Vidian artery, 535, , 551
Vidian (pterygoid) canal, 120, , 378, , 381, , 382, , 383, , 400, , 401, ,
405, , 406, , 408, , 409, , 417, , 426, , 468, , 473
venous plexus, 473
vidian nerve, 467
Vidian nerve, 382
vidian canal, 474
within vidian canal, 401
Virchow-Robin spaces, 18
Visual attention, 271
Visual attentional regions, 283
Visual blindness, primary auditory and auditory association cortex,
242–247
Visual cortex (areas 17, 18, and 19), 146, , 176, , 180, , 290, , 292, ,
441
Visual network, 256, , 257, , 258, , 280–287
cortex and optic radiations, 283
cortex subregions, 287
eccentricity maps, 286
field mapping, 284
hemifields, 285
pathway, 284
Visual perception, retrosplenial cingulate cortex, 212
Vomer, 374, , 380
W
Wackenheim line, 710, , 714, , 715
Welcher basal angle, 710, , 714, , 716
Wernicke aphasia, 290
temporal cortex, 188
Wernicke area, 54, , 188, , 290, , 292, , 293
Wernicke homologue, 292
White matter maturation, 50
White matter tract, 50–77, , 312
3T axial DTI, typical adult, 56
3T axial T1 MR
3 months, 63
3 years, 73
6 months, 65
9 months, 67
12 months, 69
18 months, 71
32 weeks premature, 59
birth, 61
3T axial T2 MR
3 months, 64
3 years, 74
6 months, 66
9 months, 68
12 months, 70
18 months, 72
32 weeks premature, 60
birth, 62
brain, 28
3T coronal DTI, typical adult, 57
3T coronal STIR MR, 75
3T diffusion MR tractography, healthy adult, 53, , 54
3T DTI, partial agenesis of corpus callosum, 77
3T MP-RAGET1 MR, partial agenesis of corpus callosum, 76
3T sagittal DTI, typical adult, 58
Working memory, 268
Z
Zygapophyseal joint. See Facet joints.
Zygapophyses. See Articular processes.
Zygomatic arch, 9, , 378, , 379, , 381
Zygomatic bone, 374, , 379
Zygomaticofrontal suture, 8
Zygomaticomaxillary suture, 8
Zygomaticotemporal suture, 8

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IMAGING ANATOMY: Brain and

Anne G. Osborn, MD, FACR

Jeffrey S. Anderson, MD, PhD

Arthur W. Toga, PhD

SECTION 1: SCALP, SKULL, AND MENINGES

Chapter 2: Cranial Meninges

Chapter 3: Pia and Perivascular Spaces

SECTION 2: SUPRATENTORIAL BRAIN

Chapter 4: Cerebral Hemispheres Overview

Chapter 5: Gyral/Sulcal Anatomy

Chapter 6: White Matter Tracts

Chapter 7: Basal Ganglia and Thalamus

Chapter 8: Other Deep Gray Nuclei

Chapter 9: Limbic System

Chapter 10: Sella, Pituitary, and Cavernous Sinus

Chapter 11: Pineal Region

Chapter 13: Primary Motor Cortex (Area 4)

Chapter 14: Superior Parietal Cortex (Areas 5, 7)

Chapter 15: Premotor Cortex and Supplementary Motor Area

Chapter 16: Superior Prefrontal Cortex (Area 8)

Chapter 17: Dorsolateral Prefrontal Cortex (Areas 9, 46)

Chapter 18: Frontal Pole (Area 10)

Chapter 19: Orbitofrontal Cortex (Area 11)

Chapter 20: Insula and Parainsula Areas (Areas 13, 43)

Chapter 21: Primary Visual and Visual Association Cortex (Areas

Chapter 22: Temporal Cortex (Areas 20, 21, 22)

Chapter 23: Posterior Cingulate Cortex (Areas 23, 31)

Chapter 25: Subgenual Cingulate Cortex (Area 25)

Chapter 26: Retrosplenial Cingulate Cortex (Areas 29, 30)

Chapter 27: Parahippocampal Gyrus (Areas 28, 34, 35, 36)

Chapter 28: Fusiform Gyrus (Area 37)

Chapter 29: Temporal Pole (Area 38)

Chapter 30: Inferior Parietal Lobule (Areas 39, 40)

Chapter 31: Primary Auditory and Auditory Association Cortex

Chapter 32: Inferior Frontal Gyrus (Areas 44, 45, 47)

SECTION 3: BRAIN NETWORK ANATOMY

Chapter 33: Functional Network Overview

Chapter 34: Neurotransmitter Systems

Chapter 36: Attention Control Network

Chapter 37: Sensorimotor Network

Chapter 38: Visual Network

Chapter 39: Limbic Network

Chapter 40: Language Network

Chapter 41: Memory Network

Chapter 42: Social Network

SECTION 4: INFRATENTORIAL BRAIN

Chapter 43: Brainstem and Cerebellum Overview

Chapter 44: Midbrain

Chapter 45: Pons

Chapter 46: Medulla

Chapter 48: Cerebellopontine Angle/IAC

SECTION 5: CSF SPACES

Chapter 49: Ventricles and Choroid Plexus

Chapter 50: Subarachnoid Spaces/Cisterns

SECTION 6: SKULL BASE AND CRANIAL NERVES

Chapter 51: Skull Base Overview

Chapter 52: Anterior Skull Base

Chapter 53: Central Skull Base

Chapter 54: Posterior Skull Base