• Tayebi MeybodiAliADivision of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA., Borba MoreiraLeandroLDivision of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA., Xiaochun Zhao, Mark C Preul, and Michael T Lawton.
• Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
• World Neurosurg. 2019 Jun 1; 126: e463-e472.

BackgroundRootlets of the lower cranial nerves create a web that limits microsurgical maneuverability in the cerebellomedullary cistern (CMC). The vagoaccessory triangle (VAT) and 2 triangles within it were defined to identify surgical routes to aneurysms of the posterior inferior cerebellar artery (PICA). Dividing the VAT into 2 triangles (suprahypoglossal [SHT] and infrahypoglossal [IHT]), although elegant, oversimplifies CMC anatomy. The triangle formed by the superior and inferior hypoglossal rootlets (hypoglossal-hypoglossal triangle [HHT]) needs consideration as well.MethodsFar-lateral craniotomy was performed on 10 cadaveric heads bilaterally. Areas of CMC triangles were calculated. Relationships between the PICA origin and the adjacent triangles were analyzed. Vertebral artery (VA) exposure and clipping lengths were recorded for each triangle.ResultsThe area of SHT was almost twice those of IHT and HHT. The average VA depth relative to VAT increased significantly when moving distally from proximal VA (P < 0.001), but VA exposure and clipping lengths were not significantly different between triangles. IHT, HHT, and SHT defined VA subsegments (V4i, V4h, and V4s), with PICA most commonly originating from V4h. Based on our cadaveric measurements, the V4 subsegments were identified with 76% accuracy in angiograms.ConclusionsBased on this study, VAT should be divided into 3 triangles, not 2. Splayed rootlets of cranial nerve XII and multiple outlet foramina create an important space different from the previously recognized SHT and IHT. These triangles provide corridors to vascular pathologies. V4 subsegments may be approximated from imaging studies and may help with preoperative planning.Copyright © 2019 Elsevier Inc. All rights reserved.

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