of the Arterial Circle (of Willis) R.J. STACEY1* AND J.B. MILES2 1National Hospital, Queen Square, London 2Walton Centre for Neurology and Neurosurgery, Liverpool
This article presents the use of magnetic resonance tomographic angiography (MRTA) of the arterial circle (of Willis) in the diagnosis of some clinically relevant abnormalities, with special reference to trigeminal neuralgia and aneurysms. Clin. Anat. 11:338–341, 1998. r 1998 Wiley-Liss, Inc.
INTRODUCTION 1996). However, the problem is in identifying those
individuals with compression pre-operatively and those Magnetic resonance imaging (MRI) has developed in whom vascular compression is responsible for recur- rapidly over the past 20 years. In addition to the rence. One of the ways in which this distinction may standard coronal, sagittal, and axial planes seen with be made is by using MRTA. CT, it is now possible to manipulate the data to examine regions of interest for any plane. More recently, physiological gating, rapid sequence acquisi- DIAGNOSTIC PROBLEMS tion, and advanced signal processing have enabled Figures 1–4 were obtained using a 1.5 Tesla Phillips imaging of dynamic processes such as the cardiac cycle MR scanner. The structures labeled are identified in and arterial blood flow. Although magnetic resonance the legends. Readers are invited to attempt identifica- angiography (MRA) has not entirely replaced conven- tion and to answer the following questions: tional angiography it is a useful adjunct. In cases where an appreciation of the vascular relations of other body Question 1 structures is desired, then MRI in combination with Can you identify the arrowed structure in Figure 1? MRA has become a valuable tool. The combination of the two has been termed magnetic resonance tomo- Question 2 graphic angiography (MRTA). This technology has In Figure 2, identify the arrowed structure. How recently been applied to the investigation of trigemi- does its arterial relationship differ from that seen in nal neuralgia (Meaney et al., 1995). In this condition Figure 1? severe facial pain is experienced in one or more divisions of the trigeminal nerve. Although the patho- Question 3 genesis of trigeminal neuralgia remains controversial Figure 3 is a coronal section through the same (Adams, 1989; Bowsher, 1998) it has been shown in a region as that shown in sagittal section in Figure 2. Can substantial number of these cases that there is direct you identify the trigeminal nerve on each side? What is vascular compression of the trigeminal nerve, usually the abnormal feature labeled with double arrow on the by branches of the superior cerebellar artery at the root reader’s left side (patient’s right side)? What are the entry zone of the nerve as it emerges from the pons structures labeled with single arrows? (Dandy, 1934). One effective treatment strategy is to separate the two structures surgically, usually with a piece of sponge-like material; the technique is termed *Correspondence to: R.J. Stacey, National Hospital, Queen Square, microvascular decompression and has good long-term London WCI 3BG. results (Mendoza and Illingworth, 1995; Barker et al., Received 6 May 1997; Revised 19 September 1997
r 1998 Wiley-Liss, Inc.
Magnetic Resonance Tomographic Angiography 339
Fig. 1. Shows a para-sagittal section through the pons in the region of the trigeminal nerve in a normal subject; ic: internal carotid artery; t: temporal lobe; p: pons; sca: superior cerebellar artery.
Question 4 Question 2: Figure 2 shows an arterial loop in
In Figure 4, what is the arrowed structure and from contact with the trigeminal nerve (arrowed) at the root what does it arise? entry zone adjacent to the pons. This is a characteristic finding in many cases of trigeminal neuralgia and it is ANSWERS AND DISCUSSION usually the superior cerebellar artery, or a branch thereof, which is responsible. During microvascular Answers decompression, this arterial loop is moved and a piece Question 1: The arrowed structure is the trigeminal of sponge or muscle placed between it and the nerve. nerve, seen leaving the anterolateral surface of the Question 3: Figure 3 shows a coronal view through pons and passing to the trigeminal cave (of Meckel) on the same region as that shown in Figure 2. On the right the superior border of the petrous temporal bone. The side (reader’s left) the compressing arterial loop shown superior cerebellar artery (sca) is clearly seen, well in Figure 2 is seen in cross-section (double arrow). On away from the trigeminal nerve. the asymptomatic left side there is no such compres-
Fig. 2. As Figure 1, but in a patient suffering from trigeminal neuralgia.
340 Stacey and Miles
Fig. 3. A coronal section through the same region as in Figure 2; p: pons.
Fig. 4. MR angiogram of the arterial circle of Willis and associated structures viewed from behind in the coronal plane; a: anterior cerebral artery; c: internal carotid artery; b: basilar artery; v: vertebral artery; m: middle cerebral artery. Magnetic Resonance Tomographic Angiography 341
sion. The single arrowed structures are the posterior which is also implicated in the pathogenesis of trigemi- cerebral arteries shown in cross-section as they pass nal neuralgia. around the cerebral peduncles. Question 4: Figure 4 shows an MRA of the circle of ACKNOWLEDGMENTS Willis including the internal carotid, vertebral and The authors thank Dr. E. Trevor S. Smith, Consul- middle cerebral vessels, in this case viewed in the tant Radiologist at the Walton Centre for Neurology coronal plane from behind. The arrowed structure and Neurosurgery for his expert assistance in the situated between the internal carotid arteries is an preparation of this article. aneurysm arising from the posterior circulation, prob- ably from one of the posterior inferior cerebellar REFERENCES arteries (branches of the vertebral arteries). The resolu- Adams, C.B.T. 1989 Microvascular compression; An alternative tion is good, but just as with conventional cerebral view and hypothesis. J. Neurosurg 57:1–12. angiography, further views of the region are required Barker, F.G., P.J. Janetta, D.J. Bissonette, M.V. Larkins and for definitive diagnosis. H.D. Jho 1996 The long-term outcome of microvascular decompression for trigeminal neuralgia. New Engl. J. Med. Once the data has been acquired from the MR 334:1077–1083. scanner it can be electronically manipulated to view Bowsher, D. 1997 Trigeminal neuralgia: An anatomically ori- the region of interest in many planes (Prost and ented review. Clin. Anat. 10:409–415. Czervionke, 1994). It is this versatility which enables Dandy, W.E. 1934 Concerning the cause of trigeminal neural- such detailed investigation of very small structures. gia. Am. J. Surg. 24:447–455. Meaney, J.F., P.R. Eldridge, L.T. Dunn, T.E. Nixon, G.H. However, as can be seen from the image quality of the Whitehouse and J.B. Miles 1995 Demonstration of neurovas- figures, the present scanners are working at, or very cular compression in trigeminal neuralgia with magnetic close to, their maximal resolution and thus image resonance imaging: Comparison with surgical findings in 52 interpretation is difficult and requires experience. One consecutive operative cases. J. Neurosurg. 83:799–805. of the ways in which the diagnosis can be further Mendoza, N. and R.D. Illingworth 1995 Trigeminal neuralgia treated by microvascular decompression: A long-term fol- refined is by giving the contrast agent, gadolinium. low-up study. B. J. Neurosurg 9:13–19. This has the effect of enhancing venous structures and Prost, R. and L.F. Czervionke 1994 How does an MR scanner the smaller arteries (0.5 mm or less), compression by operate? A.J.N.R. 15:1383–1386.
Visualization of the Peripheral Branches of the Mandibular Division of the Trigeminal Nerve on 3D Double-Echo Steady-State with Water Excitation Sequence
Visualization of the Peripheral Branches of the Mandibular Division of the Trigeminal Nerve on 3D Double-Echo Steady-State with Water Excitation Sequence
