• Neuroradiology

The Normal Anterior Inferior Cerebellar Artery

Anatomic-Radiographic Correlation with Emphasis on the Lateral Projection 1

Thomas P. Naidlch, M.D. 2 , Irvin I. Krlcheff, M.D., Ajax E. George, M.D., and
Joseph P. Lin, M.D.

Previous descriptions of the course and anatomic relationships of the anterior inferior
cerebellar artery (AICA), as visualized in the lateral projection, have not been found by
the authors. Dissection and radiography of 32 injected human cerebella show that AICA
and its major branches define the position of the pontomedullary sulcus; supra-olivary
fossette; 5th-11th cranial nerves; brachium pontis; flocculus; great horizontal fissure;
posterolateral fissure; superior semilunar lobule; inferior semilunar lobule; biventral lob-
ule; foramen of Luschka; and the choroid plexus of the lateral recess of the 4th ventricle.
With magnification and high-quality subtraction, AICA and its associated structures may
be identified in the lateral projection in the large majority of patients.

INDEX TERMS: Arteries, cerebellar. Brain, anatomy • Cerebral blood vessels, anatomy

Radiology 119:355-373, May 1976

HE ANTERIOR inferior cerebellar artery (AlGA) tery of significant size that appeared to supplement or
T carries the major arterial supply to the anterior or replace a portion of the distribution of AICA was termed
petrosal aspect of the inferior surface of the cerebellar an accessory artery, and designated as either a superi-
hemispheres. The artery, however, has remained in- or or an inferior accessory artery. In those cases with
completely described because of the difficulties en- an accessory artery, the more typical artery was desig-
countered in visualizing it adequately prior to the wide- nated "AlGA". Two arteries of significant size, neither
spread use of magnification and subtraction radiograph- of which pursued a typical course, were considered ab-
ic techniques. This paper presents a detailed analysis errant. Specimens without large middle cerebellar
of the course and anatomic relationships of AlGA in branches, representing 2-3 % of cases in other series
frontal and lateral projections. (3, 21), were excluded from this study. Because of the
limitations of photographic depth of field, the photo-
MATERIALS AND METHODS graphs of the specimens were obtained in slight de-
grees of obliquity rather than true lateral position.
Thirty-two cerebella from patients 2 months to 68
years of age, were removed at postmortem within 24 BRAIN STEM AND CEREBELLAR
hours of death. injected with a Micropaque-gelatin mix- ANATOMY (2, 10, 11. 12,24)
ture (19) via the vertebral artery, suspended carefully in
10% formalin to minimize distortion, and allowed to fix The cerebellar hemispheres are conveniently divided
for 3-12 months. Preliminary study of these specimens into a superior surface which faces the tentorium. and
demonstrated surprising lack of symmetry of the poste- an inferior surface which faces the bony confines of the
rior fossa vessels, corroborating the results of Stopford posterior fossa (Figs. 1, 2, and 7, B). This inferior sur-
and others (6, 21). Therefore, the 63 usable hemicere- face may be further subdivided into an anterior or petro-
bella available from the 32 specimens were grouped to- sal portion, which faces the posterior aspect of the pe-
gether, radiographed, dissected, and analyzed as 63 in- trous pyramids, and a posterior or occipital portion,
dependent examples of the potential courses and rela- which faces the occipital squama. The superior surface
tionships of the AICA and its branches. All measure- is sharply demarcated from the other surfaces by the
ments were made on the fixed specimens. Postfixation anterolateral (ALM) and posterolateral (PLM) cerebellar
volume changes, estimated at ±5 %, were disregarded margins (Fig. 1). The ALM extends from the anterior
(9). The results of the anatomic study were then utilized angle (A) to the lateral angle (L) and is formed by the
in the analysis of 100 normal, direct 2X magnification quadrangular lobule (0) and part of the superior semilu-
selective vertebral angiograms. nar lobule (S).
A single vessel of substantial size that pursued a typ- The cerebellar hemispheres are divided into lobules
ical course (vide infra) was termed AICA. A second ar- by deep fissures. The posterior superior fissure (PSF)

1 From the Department of Radiology, Section of Neuroradiology, New York University Medical Center, New York, N. Y. Accepted for publi-
cation in December 1975.
2 NINDS Fellow in Neuroradiology, Assistant Professor in Radiology. Current address: Department of Radiology, Montefiore Hospital and
Medical Center, 111 E. 210 St., Bronx, N. Y. 10467.
Cornelius Dyke Award Presentation, American Society of Neuroradiology, Vancouver, B. C. Canada, 1975.
Supported in part QY NINDS Grant #NSD-5433-11. elk

355
356 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 1. Surface anatomy of brain stem and cerebellum, unfixed specimen. Symbols defined in TABLE I. A. True lateral view.
B. Anterior view of pons (P), medulla (M) and the petrosal surface of the cerebellum.
Fig. 2. Surface anatomy of brain stem and cerebellum. A. True lateral view. Drawing modified from Bassett's Figure 23-4 (2). The
shading (/ / / /) indicates the quadrangular lip below the anterolateral margin (ALM). B. Anterior view.

on the superior surface of the cerebellum divides that

surface into the quadrangular lobule anteriorly and the
superior semilunar lobule posteriorly (Figs. 1 and 2).
The portion of the quadrangular lobule which lies be-
neath the anterolateral margin on the petrosal surface
of the cerebellum is the quadrangular lip (QL). The su-
perior semilunar lobule is separated from the inferior
semilunar lobule beneath it by the great horizontal fis-
sure (GHF) (•• G •• in the figures) (Figs. 1, 2, and 7).
This fissure starts in the midline posteriorly, sweeps
obliquely across the occipital aspect of the hemisphere
below the lateral angle, and then turns onto the petrosal
aspect of the hemisphere anterolateral to the brachium
pontis (BP). Here it lies between the lip of the quadran-
gular lobule anterosuperiorly and the inferior semilunar
lobule postero-inferiorly (2, 12). In lateral view the pe-
trosal portion of the GHF characteristically inclines 45°.
The GHF then extends anteriorly to pass above and lat-
eral to the flocculus (F) (suprafloccular portion of the
great horizontal fissure). The third (suprafloccular) por-
Fig. 3. Typical AICA in relationship to brain stem and petrosal
surface of the cerebellum. Antero-inferior view. Supra-olivary fos- tion of the vein of the lateral recess often runs in the
sette. Diagram modified from Bassett's Figure 28-3 (2). suprafloccular portion of the GHF (11). The biventral
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 357 Neuroradiology

Fig. 4. Typical AICA. A. Lateral view. B. Anterior view. The quadrangular lip (0), most of the flocculus (F) (dotted
in) and a portion of the biventral lobule (BV) have been resected. AICA crosses the sixth nerve, 6, superficially 5 mm ros-
tral to the pontomedullary sulcus (_._-, The short meatal loop (ML) was not related to the porus acusticus. Note the caudal
point of the caudomedial artery (CM) in the supraolivary fossette and its relationships to cranial nerves 9, 10, and 11. The
caudomedial artery (LL, BVS, AHB) outlines the inferior surface of the hemisphere.

lobule (BV) occupies the lower lateral surface of the pontomedullary sulcus (PMS) which courses anterosu-
cerebellum beneath the inferior semilunar lobule and perior to the medullary pyramid (PV) and to the olive (0)
posterior to the flocculus (Figs. 1 and 2). The inferior- to reach the supra-olivary fossette (SOF). The sixth cra-
most edge of the biventral lobule is a sharp rim of tis- nial nerve (6) emerges from the PMS at the .lateral bor-
sue known as the biventral ridge (BVR). der of the pyramid.
The posterolateral fissure (PLF) is a deep transverse- The supra-olivary fossette is the most medial portion
ly running fissure which extends from the vermis to the of the cerebellopontomedullary angle (Figs. 1 and 3)
superficial aspect of the hemisphere (Figs. 1, 2, and 5, (11, 12). It may be regarded as the confluence of the
B). It separates the flocculus from the biventral lobule PMS, posterolateral fissure, and cerebellomedullary fis-
and the posterior medullary velum and nodulus from the sure. Its relationships to the brachium pontis (BP), floc-
superior pole of the tonsil and the uvula. The peduncu- culus, and olive are illustrated in Figures 1, 3, and 17.
lar portion of the PLF runs below and behind the lateral The flocculus forms the posterolateral wall of the fora-
recess of the fourth ventricle and contains within it the men of Luschka and the lateral recess in the supra-oli-
first (peduncular) segment of the vein of the lateral re- vary fossette (Figs. 3, 17, B). A membrane of adherent
cess (11)(Fig. 15, B). arachnoid and ependyma forms the anteromedial wall.
The flocculus is a small (7-15 mm), laterally project- The choroid plexus of the lateral recess (CH) emerges
ing lobule situated at the anterolateral aspect of the from the foramen of Luschka and protrudes into the
cerebellopontomedullary angle cistern (Figs. 1, 2, and cerebellopontomedullary angle to cover the antero-in-
3). The flocculus is related superiorly to the lip of the feromedial aspect of the flocculus and the adjacent por-
quadrangular lobule and posteriorly to the biventral lob- tions of the posterolateral fissure and biventral lobule.
ule while antero-inferolaterally it presents a free sur- The roots of the 9th and 10th cranial nerves emerge
face to the lateral pontine and lateral medullary cisterns from the posterolateral medullary sulcus and become
(11). Posterosuperomedially, the flocculus is attached adherent to the membranous anteromedial wall of the
by the floccular peduncle to the nodulus of the vermis lateral recess. The 11th nerve fibers are just caudal
(Figs. 15 and 16). This peduncle forms the posterolater- (11).
al wall of the deep (peduncular) portion of the lateral re- The pons is separated from the BP by the lateral pon-
cess and the anterosuperomedial wall of the posterolat- tine sulcus (Figs. 1,2, and 3) (12). The BP on each side
eral fissure (11). The flocculus is circumscribed by the passes posterosuperolaterally into the cerebellar hemi-
numerous arteries and veins which run in the surround- spheres, deep to the overhanging lip of the quadrangu-
ing fissures. The vein of the lateral recess courses pos- lar lobule anterosuperiorly, and to the flocculus and the
tero-inferiorly to the flocculus (second or floccular seg- inferior semilunar lobule postero-inferiorly. The fibers
ment) and then superior to the flocculus (third or supraf- of the fifth cranial nerve (5) emerge from the anterosup-
loccular segment) en route to the petrosal vein at the eromedial aspect of the BP, just lateral to the lateral
anterior angle (11, 12) (Fig. 24, B). pontine sulcus and in front of the anterior angle. The fi-
The pons (P) is separated from the medulla by the bers of the seventh and eighth cranial nerves (7, 8)
358 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 5. Typical AICAs. A. lateral view. Single meatal loop. The quadrangular lip (Ql) and flocculus (F) have been partially re-
sected. The long single meatal loop (Ml) lay within the porus in situ. Note the tiny caudomedial artery (CM), twigs of supply to the lat-
eral aspect of the pons ( ~), the parallelism between the suprafloccular segment of the rostrolateral artery (SFR) on the brachium
pontis (BP) and the marginal artery (MA) on the anterolateral margin (AlM), and the characteristic hairpin turns ( ...... ) at the origins of
the inferior semilunar (IA) and biventral (BVA) lobular branches.
B. lateral view, other side same specimen. M segment. Artery of the lateral recess. The meatal loop is partially obscured by the
seventh and eighth nerves. The trigeminal point [apex of the brachial loop (Bl)] and the genu (white.Al"'" ) of the marginal artery
(MA) bracket the origin of the fifth nerve (dashed in). Resection of the biventral and inferior semilunar lobules exposes the lateral sur-
face of the tonsil (T) and the anterosuperomedial wall (* *) of the posterolateral fissure. The descending artery (DA) in the lateral
portion of the fissure gives rise to the artery of the lateral recess (AlR).

Fig. 6. The rostrolateral artery. M segment. Portions of the hemisphere abutting on the horizontal and posterolateral fissures have been
resected. A. lateral view. A single rostrolateral artery is formed by two roots passing on either side of the sixth nerve. The trigeminal point
(TP) touches the postero-inferior aspect of the fifth nerve, 5. A small recurrent choroidal artery ( +-)
and the descending artery (DA) both sup-
ply the choroid (CH).
B. Towne's projection. The relationships of the three laterally, medially and laterally-directed components of the rostrolateral artery to the
cranial nerves, 5, 7, 8, brachium pontis, flocculus (F), and hemisphere are well demonstrated. The termination of the first laterally directed
segment (*) is the descent of the meatal loop (Ml) (See text p365).

emerge from behind the inferior edge of the BP at the sixth nerve superficially or deeply (Figs. 3-6, and 8-
superolateral aspect of the supra-olivary fossette (Fig. 11). In this course it supplies the lateral aspect of the
17, A) and pass anteriorly, laterally, and, to a variable lower %of the pons and the upper medulla (1) (Fig. 5,
extent, superiorly, to lie either superior or inferior to the A). On or a few millimeters lateral to the sixth nerve,
more laterally placed flocculus. AICA bifurcates into its two major branches (Figs. 3 and
4). In view of their ultimate distribution these may be
termed the rostrolateral (RL) artery and the caudomedial
THE TYPICAL AICA
artery (eM).

In a typical case, AICA arises from the first or middle

The Rostrolateral Artery
third of the basilar artery and passes posteriorly, inferi-
orly, and laterally on the belly of the pons to cross the At its origin or after a short posterolateral course, the
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 359 Neuroradiology

rostrolateral branch (rostrclateral artery) (RL) of AICA Table I: Symbols Used in Illustrations
turns superolaterally or anterosuperolaterally. With the A Anterior angle
main trunk of AICA it forms a caudal loop on the lateral AHB Ascending hem ispheric branches
AI, AICA Anterior inferior cerebellar artery
aspect of the pons (Figs. 4, 5, 6, A, and 8-11). The ALM Anterolateral margin
most postero-inferior point reached by this caudal loop ALR Artery of the lateral recess
AS Ascending artery to the great horizontal fissure
is designated the caudal point (e) of the RL. BA Basilar artery
The RL then continues superolaterally to reach the BL Brachial loop of rostrolateral artery
seventh and eighth cranial nerves anterior to the floccu- BP Brachium pontis
BS Brachial segment
lus. On the seventh cranial nerve, eighth cranial nerve, BV Biventral lobule
and the BP, the RL describes either a single arterial BVA Biventral lobular artery
BVR Biventral ridge
loop (Figs. 5, A and 11), or, more frequently, a double BVS Biventral segment
arterial loop (Figs. 4, 5, Band 8-10). The single arterial CA Choroidal arteries
CH Choroid plexus of the lateral recess
loop is designated the single meatal loop because it is CM Caudomedial artery
related to the porus acusticus in almost %of patients CMF Cerebellomedullary fissure
DA Descending artery
(18, 22). The double arterial loop is designated the M E External auditory canal
segment because of its resemblance to the letter M. F Flocculus, Floccular loop
The M segment is viewed as consisting of a meatal FL Foramen of Luschka
FP Floccular point
loop proximally plus a brachial loop (BL) on/or close to FPD Floccular peduncle
the BP distally. G Great horizontal fissure (horizontal fissure)
I Inferior semilunar lobule
In those- cases with a single meatal loop, the RL as- IA Inferior semilunar lobular artery
cends on the anterior, superficial aspect of the seventh IAA Internal auditory artery
lAC Inferior accessory artery
nerve, frequently giving off the internal auditory artery L Lateral angle
(Fig. 5, A). The RL then forms the apex of the meatal LL Lateral loop
loop on the seventh nerve, usually near to or within the LPS Lateral pontine sulcus
M Medulla
internal auditory canal. Reversing its course it descends MA Marginal artery
postero-inferomedially onto the BP by passing between ML Meatal loop of rostrolateral artery
the seventh and eighth nerves or between the eighth
a Olive
P Pons
nerve and the flocculus. On the BP it gives off arterial PCHA Prechoroidal artery
PICA Posterior inferior cerebellar artery
feeders to supply the brachium and adjacent pons (Fig. PJ Posterior aspect of the vertebro-basilar junction
5, A)(1). PLF Posterolateral fissure
PLM Posterolateral margin
In those cases with an M segment (Figs. 4, 5, B, 6, A, PMS Pontomedullary sulcus (also _._.)
and 8-10) the RL first forms a meatal loop and then PSF Posterior superior fissure
again reverses course to ascend as the brachial loop PT Posterior turn of the lateral loop
py Pyram id of the medulla
on either the superficial aspect of the eighth nerve or Q Quadrangular lobule
on the BP deep to the eighth nerve. Not infrequently the QL Quadrangular lip
R Right
apex of the brachial loop of the M segment (trigeminal RCH Recurrent choroidal artery
point) passes sufficiently far anterosuperiorly on the BP RF Retrofloccular segment of descending artery
RL Rostrolateral artery
to touch the postero-inferior aspect of the origin of the S Superior semilunar lobule
sensory division of the trigeminal nerve, and thus SC Superior accessory artery
SCA Superior cerebellar artery
serves as an arterial landmark for that nerve (Figs. 5, B, SFG Suprafloccular portion of the great horizontal
6, 8, and 9). At the apex of the brachial loop, the RL fissure
again reverses direction and passes postero-inferiorly SFR Suprafloccular segment of the rostrolateral
artery
on the BP to complete the brachial loop and the M seg- SOF Supra-ol ivary fossette
ment. Both the single meatal loop and the M segment T Tonsil
TP Trigem inal point
lie anterior to the flocculus defining its anterior aspect V Vertebral artery
(Figs. 4, 5, 6, A, and 8-11). VLR Vein of the lateral recess
Distal to the M or the single meatal loop, the rostrola- 1 First or peduncular portion of the VLR
2 Second or floccular portion of the VLR
teral artery courses posteriorly (and usually inferiorly) 3 Third or suprafloccular portion of the VLR
on the BP to enter the suprafloccular portion of the GHF 4 Fourth ventricle
5 Trigem inal nerve
(suprafloccular segment of the RL) (Figs. 5, 6, A, and 6 Abducens nerve
8-12). The suprafloccular segment plus the brachial 7 Facial nerve
loop of the M (or the distal portion of the single meatal 8 Cochleo-vestibular nerve
9 Glossopharyngeal nerve
loop) both lie on the BP and may be considered togeth- 10 Vagus nerve
er as the brachial segment of the RL (Fig. a, A). 11 P\ccessory nerve
On the superior aspect of the flocculus at or near to •<:> 0
Caudal point of the rostrolateral artery
Caudal point of the caudomed ial artery
the posterosuperior corner, the RL divides into an as- *' Defined in context-used variably
cending branch to the GHF and a descending branch to • Defined in context-used variably
Porus acusticus
the posterolateral fissure (Figs. 6, A, 8-10, and 12). Cerebellar margins or outlines of resected tissue
The ascending artery initially courses posterosuperola- ..G .. Great horizontal fissure
Pontomedullary sulcus
terally at the 45° inclination characteristic of this por-
360 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 7. Large ascending artery defining the GHF. A. True lateral view.
B. Posterior view. Note the characteristic 45 0 inclination of the proximal (petrosal) portion of the ascending artery (AS). A side
branch ( +) of an ascending hemispheric branch of PICA (horizontal arrowheads) to the horizontal fissure anastomoses with the as-
cending artery. Above the fissure, PICA branches ( *} show a marked change in caliber (white arrowheads = PLM).

tion of the GHF and is distributed to the petrosal aspect PICA or give rise to ascending hemispheric branches
of the cerebellum (Figs. 6-9). If large, this branch may which supplement or replace the hemispheric branches
continue in the GHF for several centimeters more, of PICA.
passing below the lateral angle to gain the occipital as-
pect of the cerebellum. On the occipital surface it
courses posterosuperomedially at a shallower angle The Caudomedial Artery (CM)
and is distributed variably to the superior and the inferi-
or semilunar lobules (Figs. 6-9 and 11). The caudomedial branch (caudomedial artery) of
The descending artery initially passes inferiorly in the AICA may be found consistently, but is quite variable in
posterolateral fissure between the flocculus anteriorly size (Figs. 4, 5A, 11, and 12). From its origin on the lat-
and the biventral lobule posteriorly (Figs. 3-6, A). This eral aspect of the pons in the vicinity of the sixth nerve,
portion of the descending artery, situated directly poste- the CM passes posterosuperiorly, toward the PMS, to
rior to the flocculus, may be termed the retrofloccular describe its own caudal loop on the lateral aspect of
segment of the descending artery. Together the M seg- the pons and medulla (Figs. 3, 4, 11, and 12). This loop
ment [or single meatal loop (ML)], the suprafloccular is similar to, but situated postero-inferior to, the caudal
segment, and the retrofloccular segment form a floccu- loop of the RL described previously.
lar loop which outlines the flocculus (Figs. 3 and 5-12). When the CM is small, it will often terminate on the
The retrofloccular segment of the descending artery lateral aspect of the pons or in the PMS as a small twig
frequently gives rise to inferior semilunar and biventral supplying the pons, the PMS, the supra-olivary fossette
lobular branches which pass laterally out of the fissure and/or the 9th and 10th cranial nerves (Fig. 5, A). When
to supply the adjacent petrosal and occipital aspects of it is slightly larger, it may also contribute to the supply
the corresponding lobules (Figs. 4, 5, 8-10, and 12). of the lateral aspect of the flocculus and the biventral
Frequently this segment also gives rise to a small artery lobule.
or plexus of arteries which runs posterosuperomedially In approximately Y3 of patients in whom the CM is
in the depths of the posterolateral fissure (Figs. 5, B large, it frequently courses laterally from the supra-oli-
and 15). Because this artery or plexus accompanies the vary fossette to describe a laterally directed loop about
vein of the lateral recess, it has been termed the artery the rootlets of the 9th, 10th, and 11th cranial nerves,
of the lateral recess (11, 15). the foramen of Luschka, and the tuft of choroid plexus
When the posterior inferior cerebellar artery (PICA) which emerges from the foramen (Figs. 3, 4, 11, 12,
is small, the descending branch of the rostrolateral ar- 17, Band 22). This lateral loop of the CM lies, in order,
tery (RL) enlarges and often continues inferiorly and on the antero-inferolateral aspect of the flocculus (ante-
posteriorly on the free lateral surface of the biventral rosuperior to the rootlets), on the petrosal aspect of the
lobule, on the biventral ridge, or in the cerebellomedul- biventral lobule (lateral to the rootlets), and on the pe-
lary fissure to reach the posterior inferior aspect of the trosal aspect of the undersurface of the biventral lobule
cerebellum. This portion of the artery may be termed (postero-inferior to the rootlets of the cranial nerves).
the biventral segment of the descending artery (Figs. 8 Multiple small arteries to the choroid plexus of the lat-
and 9). The biventral segment may anastomose with eral recess often arise from the inner aspect of this lat-
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 361 Neuroradi

Fig. 8. Single typical AICA. Normal left vertebral an-

giogram-arterial phase subtraction. A. Lateral projec-
tion. The basilar artery obscures the origin of AICA (1 ).
No caudomedial artery is visualized. The rostrolateral ar-
tery forms a prominent M segment, a floccular loop (F),
an ascending (AS), and a descending (DA) artery. The
meatal loop (ML) of the M segment lies in relationship to
the subtraction artifact of the external auditory canal (E).
An inconstant infrafloccular artery probably represents
the recurrent choroidal artery ( +). The terminations of
the ascending hemispheric branches of PICA ( , , ,) de-
fine a portion of the great horizontal fissure. Note the
genu (*) of the marginal artery at the anterior angle and
the floccular point (also+).
B. Towne's projection, same patient. The apex of the
meatal loop (ML) is at the internal auditory canal ( ) ). The
medially directed segment ( ! ) represents the descent
of the meatal loop plus the ascent of the brachial loop.
Note the parallelism between the loop (4+) and the mar-
ginal artery (MA), and the characteristic angulation in the
course of the ascending artery (AS).

Fig. 9. Diagram of brainstem and cerebellar anatomy established from the course of AICA (cf. Fig. 8, A). The ascent of the meatal loop
(ML) marks the ventral superficial aspect of the seventh nerve, 7, in most cases, and the crotch of the M marks the approximate site of the
eighth nerve, 8. The brachial loop and the suprafloccular segment (SF) of the rostrolateral artery define the brachium pontis, and the marginal
artery (MA) of the superior cerebellar artery delineates the anterolateral margin. The genu of the marginal artery (*) is the anterior angle (A).
MA, SFR and the 45 0 portion of AS define the quadrangular lip (\\ \ \). The terminations of the multiple ascending hemispheric branches of
PICA t , , , ) define the great horizontal fissure. The distal ascending artery runs above the horizontal fissure (normal variation). The de-
scending artery (DA) defines the anterior aspect of the biventral lobule. The vertebrobasilar junction (PJ), caudal point (.) of the rostrolateral
artery (RL), and floccular point (.) mark the location of the pontomedullary sulcus (_._.).

eral loop (Fig. 17). Distal to the loop the biventral seg- ment or replace the hemispheric branches of PICA
ment of the CM turns postero-inferiorly on the lateral (Figs. 4 and 12).
aspect of the biventral lobule, on the biventral ridge, or
within the cerebellomedullary fissure to reach the pos-
DETAILED ANATOMY AND ANGIOGRAPHIC
terior surface of the cerebellum (Figs. 4, 11, 17, and APPEARANCE
18). In a manner analagous to the descending branch of
the RL, the CM may also anastomose with PICA or give A single typical AICA was encountered in 60 % of
rise to ascending hemispheric branches which supple- specimens (Fig. 4). The combination of "AICA " and
362 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 11. Typical single AICA, large rostrolateral and caudom-

edial arteries. Lateral projection. The single meatal loop (ML) and
floccular loop (F) of the rostrolateral artery are well defined. The an-
Fig. 10. Single typical AICA, rostrolateral artery. Lateralprojec- terior convexity of the ascending segment of the meatal loop ( J... )
tion. No caudomedial branch is seen. The characteristic hairpin turn is an infrequent variation. (+) = the superior cerebellar arteries at
( J.-) marks the posterolateral fissure. The ascending artery ( ! ) is the posterolateral margin, and ( t) = the great horizontal fissure
small, but ascending hemispheric branches of PICA define a portion (G). Small tortuous vessels ( .... ) arising from the descending artery

margin is identified (*) +).

of the horizontal fissure ( A small branch to the anterolateral
(cf. Fig. 6, A).
(DA) may represent the arterial plexus of the lateral recess (cf. Fig.
4). LL, BVS and AHB outline the inferior surface of the hemisphere.

Fig. 12. Large rostrolateral and caudomedial branches, common AICA-PICA trunk. A. Lateral projection. No PICA is seen. Distal to the
posterior turn (+), the caudomedial artery forms the tonsillar loop (T) and gives off hemispheric branches to supply the PICA distribution.
B. Straight anteroposterior projection (earlier arterial phase, tonsillar loop not filled). The caudomedial artery first passes postero-inferior-
Iy to its caudal point (0) and then around the cranial nerve roots (" LL, -+. =$=) toward the posterior turn (+).

one accessory artery of either the superior or inferior 4 and 5 A). No single AlGA was seen to arise from the
type was observed in 29 % (Figs. 19, 20, and 22) and distal third of the basilar artery. In those specimens with
the combination of "AICA" and both superior and inferi- an "AlGA" and a superior accessory artery, AICA al-
or accessory arteries in 1% (Fig. 21). Two aberrant ar- most always arises from the first third of the basilar ar-
teries were identified in 10%. tery (Fig. 22). In those specimens with an "AlGA" and
The anterior inferior cerebellar arteries arise from an inferior accessory artery, "AlGA" almost always
the lateral aspect of the basilar artery at variable levels. arises from the second third of the basilar artery (Fig.
In those cases with a single AlGA, the origin is approxi- 19). In the 1 case with an "AlGA", a superior accessory
mately equally frequent from the first third (47 %) and artery, and an inferior accessory artery, each artery
from the second third (53 %) of the basilar artery (Figs. arose from its own third (Fig. 21). "AlGA" is larger than
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 363 Neuroradiology

either its superior or its inferior accessory artery in

70 % of cases (Figs. 20 and 22 left side). In each case
in which "AICA" was smaller than its accessory artery,
it was still a vessel of significant size (Fig. 19).

Relation To The Sixth Nerve

Whether AICA crosses the sixth nerve superficially

or deeply appears to be related to the distance along
the nerve from the PMS to the point at which the artery
actually crosses the nerve. In all cases in which the ar-
tery crosses the nerve less than 6 mm rostral to the
PMS, the artery was found superficial to the nerve (Fig.
4). In all cases in which the artery crossed the nerve
from 8 to 11 mm rostral to the PMS, the artery was
found to cross deep to the sixth nerve (Fig. 5, A). These
relationships held even when there were multiple arte-
ries each crossing the nerve at a different level (Fig. 6,
Fig. 13. Localization of the pontomedullary sulcus. In order from
A). The region from 6 to 8 mm rostral to the PMS ap- antero-inferior to posterosuperior the four squares (_) along the
pears to represent a transition zone in which the artery pontomedullary sulcus (- - -) represent the posterior aspect of the
may pass superficial to, deep to, or through the sixth vertebrobasilar junction, the caudal point of the rostrolateral artery,
the caudal point of the caudomedial artery. and the floccular point.
nerve (Fig. 20) (4, 21). When AICA is more than 11 mm
The numbers represent the range (in millimeters) over which these
rostral to the pontomedullary fissure it bears no relation points may be found in 90 % or more of cases.
to the sixth nerve. The point of origin of AICA from the
basilar artery and the distance between the caudal point
and the PMS bore no constant relationship to whether
90 % of cases (Figs. 4 and 22). The caudal point of the
the artery crossed the nerve superficially or deeply.
caudomedial branch also serves as a landmark for the
The bifurcation of AICA and the caudal point of the
supra-olivary fossette, and lies on its anterior border
RL may help to localize the sixth nerve angiographical-
(42 %), or deep within the supra-olivary fossette (46 % )
Iy. AICA usually divides into its rostrolateral and caudo-
(Figs. 4 and 22). (d) The flocculus and floccular loop al-
medial branches on or within a few millimeters lateral
ways straddle the PMS, marking its posterosuperior end
to the sixth nerve (Fig. 4). In 5 % of cases it divides a
(Figs. 5, A, 6, and 20). The midpoint of the inferior bor-
few millimeters medial to the sixth nerve (Fig. 16, A),
der of the floccular loop (the floccular point) lies from 4
and in 5 % at or distal to the seventh and eighth nerves
mm caudal to 4 mm rostral to the posterosuperior end
anterior to the flocculus. The caudal point of the RL
of the pontomedullary sulcus (PMS) in 96% of cases. In
usually lies lateral to the sixth nerve (Figs. 5, A and 20),
20 % of cases the floccular point lies exactly at the sul-
but in 20 % of typical cases it lies at the sixth nerve
cus.
(Fig. 4). In the typical case therefore the sixth nerve
The combination of these four arterial landmarks,
may be found at the AICA bifurcation, at or antero-infe-
each related to a slightly more posterior and superior
rior to the caudal point of the RL (Figs. 8, 9, and 11).
portion of the PMS, allows a reasonable estimate of the
position of the sulcus in most cases (Figs. 8-11 and
Pontomedu/lary Sulcus 24). The use of four criteria enables the variant position
of anyone of these landmarks to be recognized and
Four distinct landmarks were observed to lie in close discounted (Fig. 5, A).
relationship to the PMS (Fig. 13). (a) The posterior as-
pect of the vertebra-basilar arterial junction (PJ) lies
Rostro/ateral Artery (RL)
from 4 mm caudal to 4 mm rostral to the anterior mid-
line portion of the PMS in 90% of cases (Figs. 4, 19, The RL is usually larger than the caudomedial artery
and 20). (b) The caudal point of the RL lies from 2 mm (CM) (80% of specimens), except when the caudom-
caudal to 5 mm rostral to the lateral portion of the PMS edial branch is supplementing flow to the distribution of
in 90 % of those specimens with a single AICA or an a small PICA (Fig. 4), or the marginal branch of the su-
"AICA" plus accessory arteries (Figs. 4, 6, and 20), and perior cerebellar artery supplies the region of the GHF
in 80 % of those classified as aberrant. (c) When the (8, 16).
caudomedial artery (CM) is of sufficient size to have a In more than 90 % of cases with an AICA or "AICA"
definable caudal point, this lies from 4 mm caudal to 2 the RL describes either an M segment or a single mea-
mm rostral to the posterolateral portion of the PMS tal loop on the seventh and eighth nerves and the bra-
(Figs. 4 and 22) and is a more accurate indicator of the chium pontis. The M configuration is present in approxi-
position of the PMS than the caudal point of the RL in mately 70 % of specimens, and the single meatal loop
364 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 14. A. Bilateral AICA symmetry in lateral projection, with differing appearance in Towne's projection, B. Note the open supero-
medial arterial knuckle (i-+) on the left rather than the figure-of-eight on the right. The suprafloccular segment (SFR) and the descending ar-
tery (DA) form an acute angle (*) in Towne's projection. Note the proximity of the genus (+) of the marginal arteries to the brachial loops
(small arrowheads) in both lateral and Towne's projections defining the fifth nerve origins. (cf. Fig. 6, B).

is present in approximately 23 %. No M segment or just lateral to the brachium. The RL then reaches the
loop was identifiable in any of the specimens classified BP, distal to the "brachial" loop, by coursing between
as aberrant. the eighth nerve and the flocculus to begin the supraf-
Meatal Loop (ML): The M segment most frequently loccular segment.
begins its ML with an upsweep on the anterosuperficial When the RL forms a single meatal loop, this loop
aspect of the seventh nerve (80-85 %) (Figs. 4, 6, and most frequently ascends on the anterosuperficial as-
22, right side). Less frequently the upswing is on the su- pect of the seventh nerve (55 %) (Figs. 5, A, 19, and
perficial aspect of the groove between the seventh and 20). Less frequently it ascends superficial to the groove
eighth nerves (12-15 %) (Fig. 22, left side), or in the between the seventh and eighth nerves (22 %), or su-
groove between the eighth nerve and the flocculus perficial to the groove between the eighth nerve and
(5 %). The peak of the ML usually lies on the superficial the flocculus (22 %). It then descends superficial or
aspect of the seventh nerve. In 64 % of cases it lies deep to the seventh and eighth nerves to gain the BP in
near to, or within, the internal auditory canal (Fig. 22, the same fashion as the ML of the M segment.
right side), but in 36 % of cases the apex of the loop is Internal Auditory Artery: In our specimens the inter-
not related to the porus (Figs. 4 and 6) (17, 18, 22, 27). nal auditory artery was identified with certainty in only
The descending limb of the ML of the M segment % of cases. In 85 % of these it was seen to arise from
may lie on the superficial aspect (Figs. 4, 6, 21, and 22, the upswing (70 %), apex (25 %), or downswing (5 %) of
right side), or the deep aspect (Fig. 5, B) of the seventh the ML (Figs. SA, 21, and 22). In 10% the internal audi-
nerve, or exactly between the seventh and eighth tory artery was a separate branch of the basilar artery,
nerves. In approximately Y4 of cases it extends further which arose several millimeters rostral to the origin of
postero-inferiorly to lie on either the superficial or deep AICA. The other 5 % of internal auditory arteries identi-
aspect of the eighth nerve. The crotch of the M lies (a) fied had highly variable origins. A detailed analysis of
superficial to the seventh and eighth nerves overlying the internal auditory artery has been presented by
the groove between them (25 %) (Fig. 4), (b) actually Walker (28).
within the inter-neural groove (25 %) (Fig. 6), (c) super-
ficial or deep to the eighth nerve (12% each) (Fig. 22),
Angiography of the M Segment
or (d) between the eighth nerve and the flocculus
(25%). Angiographically, the M segment is usually well de-
Brachial Loop: If the rostrolateral artery did not pass fined in both frontal and lateral projections (Figs. 8-12,
deep to the seventh and eighth nerves and onto the bra- 14, 18, 24, and 25). The ascent of the M segment or the
chium pontis (BP) in the descending portion of the ML, it ML may be taken to indicate the anterosuperficial as-
usually does so just distal to the crotch of the M by pect of the seventh cranial nerve in most cases. The
passing between the seventh and eighth nerves (Fig. 6), crotch of the M may be taken to indicate the approxi-
or between the eighth nerve and the flocculus (Fig. 4) to mate position of the eighth cranial nerve in many
lie on the BP deep to and extending a variable distance cases. In lateral projection, the portion of the ML as-
anterosuperior to both the seventh and eighth nerves cending along the seventh and eighth nerves is usually
(85 %) (Figs. 4, 5, B, and 6). Rarely the "brachial" loop either convex posterosuperiorly or horizontally (Figs. 8,
may lie on the superficial aspect of the eighth nerve A, 10, and 12). In a small number of normal patients
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 365 Neuroradiology

(Fig. 11), especially when the RL is tortuous, or has ab- tions of the M segment. As a function of projection this
errant origin, as from PICA (Fig. 18), this ascending medially-directed segment appears to lie above, lie
segment is concave posterosuperiorly. At present, we below, or cross the portion of the RL proximal to the
regard reversal of the curvature of this segment from porus (Figs. 8, B, 14, B, and 25, A). (c) The second lat-
convexity posterosuperior to concavity posterosuperior erally-directed segment immediately distal to the me-
as potentially abnormal and recommend further evalua- dially-directed segment represents that portion of the
tion of the patient. In frontal view, the apex of the ML is artery on the BP that runs laterally and posteriorly
most often visualized just at or within the porus of the towards the hemispheres before bifurcating into as-
internal auditory canal (Figs. 8, Band 14, B). In lateral cending and descending arteries, l.e., the brachial seg-
projection the peak of the ML is visualized in apparent ment (Fig. 6). In patients with a single ML, this laterally
relationship to the external auditory canal (Figs. 8, A directed segment usually corresponds to the distal por-
and 9). In 36 % of cases the meatal loop is not related tion of the descent of the ML plus the suprafloccular
to the porus or the vessel is aberrant. segment. In patients with an M segment, it usually cor-
The brachial segment of the RL defines the position responds to the descent of the brachial loop plus the
and orientation of the BP and the marginal artery the suprafloccular segment. Less frequently, it may include
position and orientation of the anterolateral margin and more proximal portions of the descent of a single ML or
quadrangular lip. In lateral projection one can see the the ascent of the brachial loop of an M. In both groups
brachial segment on the BP lying parallel and just ant- this laterally-directed segment lies inferomedial and
ero-inferior to the marginal artery on the anterolateral parallel to the portion of the marginal artery on the an-
margin (Figs. 8-10, 12, and 14, A). Occasionally these terolateral margin. This second laterally-directed seg-
arteries may appear to overlie or even cross each other ment lies first anterosuperior to the flocculus and then
slightly (Fig. 23). directly superior to it. In most cases, it defines the loca-
The location of the BP may be confirmed in lateral tion of the BP and its distal portion defines the top of
venous phase by visuaHzing the third (suprafloccular) the flocculus (Figs. 8, B, 14, B, and 25, A).
segment of the vein of the lateral recess (Fig. 24), the The series of loops visualized in Towne's projection
suprafloccular segment of the vein of the GHF, or a often shows an unusually prominent superomedially di-
prominent brachial tributary of the precentral cerebellar rected arterial knuckle at or just distal to the porus
vein (11, 12). When present, the vein of the anterolater- acusticus (Figs. 6, 8, B, and 14, B). This knuckle repre-
al margin defines that structure (12). sents an exaggeration of the medially-directed and lat-
In the Towne's projection, the M segment or ML erally-directed segments discussed above and is most
forms an exceedingly complex series of overlapping prominent whenever there is an enlarged ML, 'brachial
vessel loops (6). Slight changes in the degree of angu- loop, or suprafloccular segment. It appears to arise at
lation of the x-ray beam and slight variations in the approximately right angles to the superolateral line es-
course of the rostrolateral branch produce significant tablished by the pontine portion of the RL proximal to
variations in their radiographic appearance. However, the knuckle and by the ascending artery within the pe-
this series of loops can frequently be analyzed into trosal portion of the GHF distal to the knuckle (Figs. 8,
three components by bearing in mind that the RL on the B, 14, Band 25, A). Because this loop lies predomi-
seventh and eighth nerves lies lateral to the BP and that nantly on the BP, its position and orientation define the
the BP passes laterally, posteriorly, and superiorly as it location and inclination of the brachium in the Towne's
diverges out into the hemisphere (Figs. 2 and 3). (a) In projection. In many cases the lateral portion of the
Towne's projection the first laterally-directed segment knuckle defines the top of the flocculus.
of these loops represents the passage of the RL across Trigeminal Nerve: In 40 % of cases the brachial
the belly of the pons and along the seventh and eighth loop of the M segment extends anterosuperiorly to lie
cranial nerves to the region of the porus acusticus within 2 mm postero-inferior to the origin of the sensory
(Figs. 6, 8, B, and 14, B). The distal extent of this later- division of the trigeminal nerve. The apex of such a pro-
ally-directed portion usually corresponds to the apex of nounced brachial loop may be termed the trigeminal
the ML at the porus. (b) The next medially-directed seg- point and is utilized angiographically to approximate the
ment of the M or of the single ML represents whichever position of the trigeminal nerve origin in both frontal
portions of the RL actually pass from the nerves onto and lateral projections (Figs. 8, 9, and 14). Because the
the BP. It also includes any portion of the artery on the trigeminal point approximates the postero-inferior as-
BP that runs anteromedially back toward the fifth nerve pect of the fifth nerve origin, and the genu of the mar-
and the pons (Fig. 6). In patients with a single ML, this ginal artery at the anterior angle approximates the post-
medially directed segment usually corresponds to the erosuperior aspect of the fifth nerve origin, these land-
proximal portion of the descent of the ML. In patients marks may be utilized angiographically to bracket the
with an M segment, the medially-directed segment usu- nerve origin (Figs. 5, B, 6, 8, and 14), Occasionally, the
ally corresponds to the descent of the ML and/or the course of the superior accessory artery will outline the
ascent of the brachial loop. In unusual cases the me- antero-inferior aspect of the fifth nerve origin (Figs,
dially-directed segment may correspond to other por- 21-23).
366 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 15. Arteries of the lateral recess. A. True lateral view. B. Postero-inferior view. Note the artery of the lateral recess (ALR) cours-
ing with the vein of the lateral recess (VLR) in the peduncular portion of the posterolateral fissure, and the supratonsillar and lateral tonsillar
tributaries(+ ) of the vein of the lateral recess. The artery of the lateral recess which lies below and behind the choroid plexus of the lateral
=
recess (CH) appears to lie above it due to projection in the postero-inferior view. (TA lateral tonsillar attachment).

Floccular Loop: Anatomically and angiographically, 11, and 24, A). It is a complementary landmark to the
the position of the flocculus is defined in lateral projec- vein of the GHF (12).
tion by the components of the floccular loop: the M Occasionally, the descending branch of the RL gives
segment or meatal loop (ML) anteriorly; the suprafloc- rise to large biventral and inferior semilunar lobular
cular segment posterosuperiorly; and the retrofloccular branches which pass across the petrosal and occipital
segment postero-inferiorly (Figs. 5-12 and 24, A). The surfaces of the hemisphere to reach the GHF. These
bifurcation of the suprafloccular segment usually de- may be confused with the ascending artery (Fig. 4),
fines the posterosuperior angle of the flocculus at the especially if the ascending artery is postfixed and origi-
confluence of the GHF and posterolateral fissures (Figs. nates from the retrofloccular segment. Ascending
6, 8, and 11). A complete (three-sided) floccular loop is hemispheric branches of PICA (or of AICA when this re-
visualized in many lateral vertebral angiograms. Occa- places PICA) frequently send numerous perpendicular
sionallya four-sided loop may be formed by the addition branches into the depths of the GHF and then decrease
of an inconstant, infrafloccular branch (Fig. 8). When in caliber (Fig. 7). In the lateral projection, identification
the floccular loop is anomalous, the vein of the lateral of these multiple perpendicular branches and of the
recess may help to localize the flocculus (Fig. 24). In "petering out" of the ascending hemispheric branches
straight anteroposterior projection and Towne's projec- defines the location of the fissure and its relationship to
tion, the retrofloccular segment may be identified only if the ascending branch of the RL (Figs. 8, 9, and 24, A).
large and not obscured by overlying vessels (Figs. 6, B The marginal branch of the superior cerebellar artery at
and 14, B). In both these frontal projections the retro- the anterior angle and on the anterolateral margin es-
floccular segment forms an acute angle with the supraf- tablishes the relationship of the ascending artery to
loccular segment. The suprafloccular segment extends these structures (Figs. 8 and 11). The curving of the su-
postero-inferolaterally to this angle and the retrofloccu- perior cerebellar artery branches as they descend over
lar segment extends postero-inferomedially from the the posterolateral margin (Fig. 11) establishes the rela-
angle (Figs. 3, A and 14, B). tionship of the ascending artery to the posterolateral
margin. A marginal artery that actually enters the GHF
may be utilized as a landmark for the fissure (8, 16).
Ascending Artery to the Great Horizontal Fissure (GHF)
Use of these multiple criteria clearly delineates the
The ascending artery supplies the quadrangular lip, contours and landmarks of the upper portions of the pe-
the superior surface of the quadrangular lobule and the trosal and occipital surfaces of the hemisphere and
superior and inferior semilunar lobules. It is of good provides a diagram of its surface anatomy.
size in 75% of cases and quite small in 14%. It may be In the frontal projection, the portion of the ascending
replaced by a branch of the superior cerebellar artery artery in the GHF describes a characteristic acute, lat-
(8). Angiographically the ascending branch of AICA may erally convex, angle as it passes first posterosuperola-
be taken to represent the GHF on the petrosal aspect of terally to the lateral edge of the cerebellum below the
the hemisphere in almost all cases and on the occipital lateral angle (L), and then posterosuperomedially on the
surface of the hemisphere in most cases (Figs. 8, A, 9, occipital surface of the cerebellum to reach the posteri-
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 367 Neuroradiology

Fig. 16. Prechoroidalloop. A. Lateral view. The small prechoroidal artery (PCHA) arises from the caudomedial artery (CM) and passes
toward the posterolateral fissure.
B. Postero-inferior view. Lateral is to the reader's left. BV, I, T, and most of the vermis are resected. The prechoroidal branch (PCHA)
loops over the flocculus (F) into the lateral recess of the fourth ventricle where it extends along the length of the choroid plexus of the lateral
=
recess to the lateral angle of the fourth ventricle. (N nodulus).

or cerebellar incisura in the midline (Figs. 8, Band 25, the vein of the lateral recess, to reach the supratonsil-
A). It will be seen medial to the marginal artery and the lar portion of the posterolateral fissure (15).
other superior cerebellar artery branches that run on
the perimeter of the superior surface of the cerebellum
Choroidal Arteries
(Fig. 25, A). The normal variant of the ascending artery
that runs on the superior semilunar lobule above the The arterial supply to the choroid plexus of the later-
GHF and near to the lateral angle may be detected by al recess is from variable (often multiple) sources. In
its usually lateral position (Fig. 8). some cases, a small recurrent choroidal artery origi-
nates from the ML of the rostrolateral artery (RL) and
Descending Artery and the Artery of the Lateral Recess passes postero-inferiorly beneath the flocculus to sup-
ply the choroid plexus (Figs. 6 and 20). In other cases,
In most cases, the descending branch of the RL (de- the choroidal supply arises from the caudomedial artery
scending artery) arises from the bifurcation of the su- (CM), from an inferior accessory artery, or from loops
prafloccular segment of the RL (Figs. 4-6, 8-12, 14, of PICA in the cerebellomedullary fissure.
and 24, A). Occasionally, this artery arises from a supe- In %- Y3 of specimens the choroid plexus was sup-
rior accessory artery (Figs. 21 and 22), an ascending pi ied by a modest arterial branch of the basilar, CM, or
branch of PICA, or from the superior cerebellar artery. inferior accessory artery designated the prechoroidal
The descending artery could be identified in 87 % of artery (Figs. 16 and 22). This artery is characterized by
specimens, but was quite small in %of these. its laterally looping course and by its lack of a caudal
The retrofloccular segment of the descending artery point at the pontomedullary junction.
usually gives rise to arterial feeders to the adjacent bi- The lateral loop of the CM or of an inferior accessory
ventral and inferior semilunar lobules (Figs. 4, 5, A, artery quite frequently also supplies the choroid plexus
8-10, 12, 14, and 22). These branches course laterally of the lateral recess. Single or multiple small branches
to emerge from the posterolateral fissures and then arise from the inner aspect of the lateral loop, usually
pass posteriorly or posterosuperiorly over the JateraJ- just proximal to the posterior turn, and quickly form a
most aspect of the biventral and inferior semilunar lob- spray of 3-4 small, almost parallel vessels on the cho-
ules of the cerebellum. A characteristic hairpin curve roid plexus (Fig. 17). These ramify on the plexus and
(convexity downward) marks their point of emergence pass with it toward the lateral angle of the fourth ventri-
from the posterolateral fissure (Figs. 5, A, 10, 12, and cle.
14).
In % of all specimens (% of those with modest or
Caudomedial Artery ( CM)
large descending arteries) the proximal 1-2 em of the
retrofloccuJar segment give rise to the artery of the lat- In approximately Y3 of specimens with a large CM ar-
eral recess (Figs. 5, Band 15). This passes posterosu- tery and in % of those with a large inferior accessory
peromedially in the peduncular portion of the postero- artery, a lateral arterial loop is formed in relation to the
lateral fissure, below and behind the lateral recess and anterosuperior, lateral, and postero-inferior aspects of
368 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 17. Choroidal supply from the lateral loop. A. Lateral projection. Cranial nerves 9-11 and the flocculus are removed. The inferior
=
accessory artery (lAC) describes a typical lateral loop which gives off a choroidal trunk ( 'X). (+ supra-olivary fossette).
B. Anterior view, second specimen. The ninth, 9, and tenth, 10, cranial nerves are retracted anteromedially. A black circle marks the fora-
men of Luschka. Note the anatomic relationships of the supra-olivary fossette (covered by the retracted nerves), and the structures surround-
=
ing the foramen of Luschka (ct. Fig. 3). ( ~ ) choroidal trunk.

turns postero-inferolaterally across the flocculus and

across the posterolateral fissure to lie on the petrosal
aspect of the biventral lobule lateral to the exiting root-
lets of the 9th, 10th, and 11th cranial nerves at the
point where they pass into bone (Figs. 4, 19, and 22,
left side). At the postero-inferior extent of this row of
rootlets, or at a variable distance postero-inferior to
that, the loop turns medially or anteromedially deep to
the 11th and 10th nerves to reach the postero-inferior
aspect of the choroid tuft which it supplies (Figs. 4, 17,
B, and 22, left side). The artery then turns posteriorly or
postero-inferiorly in the cerebellomedullary fissure, on
the biventral ridge, or on the lateral aspect of the biven-
tral lobule to reach the posterior aspect of the hemi-
sphere (Figs. 3, 4, and 17). The lateral loop is markedly
foreshortened in true lateral projection. This foreshort-
ening plus the reversals of curvature at the caudal point
anterior to the rootlets and at the posterior turn posteri-
or or deep to the rootlets, permit ready identification of
this loop (Figs. 4, 11, 12, and 18)
Fig. 18. Aberrant origin of AICA. Lateral projection. The rostra- When present the lateral loop may be used to define
+).
lateral artery (RL) arises directly from PICA ( The anterior con-
the medial aspect of the petrosal surface of the hemi-
vexity of the ascending portion of the meatal loop is common in
AICAs arising aberrantly (ct. Figs. 4 and 9). sphere (Figs. 11, 12, and 18). Distortions of that surface
will be reflected in an alteration of the plane of the lat-
eral loop. Normally the lateral loop should be closed on
the 9th, 10th, and 11th cranial nerve roots, the foramen angiograms in lateral projection and widely open in the
of Luschka, and the choroid tuft emerging from the anteroposterior projection (Figs. 4, 11, 12, 17, and 18).
foramen (Figs. 4, 17, 19, and 22, left side). This loop Opening of the lateral loop in lateral projection and
commences at the caudal point of the eM (or inferior closing of the loop in anteroposterior projection should
accessory artery) within or just anterior to the supra-oli- be taken to indicate abnormality. Because of the nor-
vary fossette. From the caudal point, the lateral arterial mally partially closed configuration of the loop in
loop turns anterosuperolaterally, usually lying first di- Towne's projection, opening or closing of the loop in
rectly on the nubbin of choroid superior to the ninth this projection is difficult to appreciate unless marked.
nerve (Fig. 17, A), and next on the antero-inferolateral Because the lateral loop lies on the sloping petrosal
aspect of the flocculus (Figs. 3 and 4). The loop then surface of the cerebellum, the lateral loop almost al-
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 369 Neuroradiology

ways inclines postero-inferiorly from the caudal point to

the posterior turn (Figs. 11 and 18). Very rarely, the lat-
eral loop lies in a true horizontal plane. Reversal of the
postero-inferior inclination of the lateral loop is abnor-
mal.
The inferomedial aspect of the cerebellar hemi-
sphere posterior to the lateral loop is defined by the bi-
ventral segments of the eM or inferior accessory artery
(Figs. 4, 11, 17, and 18). The ascending hemispheric
branches outline the back and sides of the hemisphere.
The lateral loop, biventral segment, and ascending
hemispheric branches may be utilized in conjunction to
define the entire inferior surface of the cerebellum
(Figs. 18 and 19). Even when a CM or inferior accesso-
ry artery is sufflciently aberrant not to form a lateral
loop, it may still outline the undersurface of the laterally Fig. 19. "AICA" plus a large inferior accessory artery supple-
projecting bulk of the cerebellum (Fig. 20). menting supply to the PICA distribution. PICA is small. The large in-
ferior accessory artery (lAC) pursues the course already described
forthe cauclomedial artery.
Cranial Nerves 9, 10, and 11

The positions of the 9th, 10th, and 11th cranial

nerves, the foramen of Luschka, and the choroid tuft
emerging from the foramen may be established from
the location of the lateral loop in most cases (Figs. 4,
17, 19, and 22). In 65% of specimens, the widest ex-
tent of the lateral loop bracketed these structures suffi-
ciently closely to be utilized as a landmark for them
(Figs. 3, 4, and 22, left side). However, in more than %
of these cases the narrower area defined by the caudal
point and posterior turn of the lateral loop bracketed the
structures more accurately than did the widest extent of
the lateral loop (Fig. 17, A). Angiographically, therefore,
use of the caudal point and posterior turn, or of the full
extent of the lateral loop, should provide approximate
anatomic localization of the 9th, 10th and 11th cranial Fig. 20. "AICA" plus inferior accessory artery coursing on the
nerves, the foramen of Luschka, and the choroid tuft in lateral aspect of the biventral lobule. Lateral view. Portions have
been resected; PICA is small. "AICA" (rostrolateral artery) pierces
%of patients (Figs. 11, 12, and 18). In the absence of a the fibers of the sixth, 6, nerve 7 mm rostral to the pontomedullary
lateral loop, the confluence of the lower end of the pos- sulcus (inset). A recurrent choroidal artery ( =F) arises from the
terolateral fissure (defined by the retrofloccular seg- meatal loop.• = the floccular point.
ment) and the pontomedullary sulcus (defined in Fig. 13)
may be taken to indicate the position of these same
structures (Figs. 8 and 9). while the vermian supply arises from a smaller "PICA"
trunk. Because of its variable, often confusing, appear-
ANATOMle VARIANTS ance and its significance in diagnosis, the common
Anomalous Origins AICA-PICA trunk will be the subject of a separate re-
port.
In rare cases AICA may arise from the vertebral ar-
Accessory Arteries
tery (21) or even from the cavernous portion of the ca-
rotid artery (20). More frequently AICA may originate An inferior accessory artery of significant size was
from PICA either proximally, from a short common demonstrated in 20 % of specimens. This artery may be
trunk, or more distally from the lateral or posterior me- regarded in almost all respects as a caudomedial
dullary segments of PICA (Fig. 18). After an initial branch of AICA which has acquired a separate origin
anomalous course by which it regains its normal posi- from the basilar artery, caudal to the origin of AICA. Its
tion, such an AICA may pursue a typical path with M course, distribution and variations are as described for
segment, floccular loop, and ascending and descending the CM (Figs. 17, A and 19).
arterial branches (Fig. 18). PICA may also arise from A superior accessory artery is a variant found in ap-
AICA. The complete supply to the PICA distribution may proximately 15 % of specimens. This artery most fre-
arise from the CM (Fig. 12) or only the hemispheric quently arose from the distal Y3 of the basilar artery, but
supply to the PICA distribution may arise from the CM, in 1 case arose from high in the middle %of the basilar
370 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 21. "AICA" plus large superior and inferior accessory arte- Fig. 22. Bilateral superior accessory arteries. Prechoroidal
ries. Lateral view. The superior accessory artery (SC) pursues a typ- loop. Water's view, unfixed specimen. Bilateral superior accessory
ical course. F = bed of resected flocculus. A small "AICA" forms a arteries (SC) cradst the roots of the trigeminal nerves, 5, and extend
meatal loop ( , ) on the seventh nerve. Its ascending branch (+) well onto the quadrangular lip (QL) before turning postero-inferome-

retracted medially) *=
anastomoses (~) with the superior accessory artery. Inset: (9, 10
Foramen of Luschka.
dially into the posterolateral fissures (PLF) as descending arteries.
Note the course of the prechoroidal artery ( ! ) on the right.

Fig. 23. Superior accessory arteries. A. Lateral view. A large superior accessory artery (SC) appears to cradle the origin of
the fifth nerve, 5, as judged by its curvature at that point in relationship to the genu (*) of the marginal artery (MA) above. "AICA"
forms a caudal loop ( ~ ) and suprafloccular (SFR) segment without any sharply defined meatal or brachial loops.
B. Straight anteroposterior projection; earlier arterial phase.

artery. Superior accessory arteries pursue a tortuous graphically these features of the superior accessory ar-
path, coursing postero-inferolaterally on the lateral as- tery are readily demonstrated.
pect of the high pons to pass immediately ventral and In some cases the course of AlGA and its branches
deep to the fifth nerve (Figs. 21 and 22). They then con- is more complex than that described above. Redundant
tinue posterolaterally, usually passing superior to the branches may describe complete loops about the floc-
seventh and eighth nerves (% cases) on the quadrangu- culus and redundant segments of arteries may loop
lar lobule and/or within the suprafloccular portion of the deep within fissures they ordinarily pass straight
GHF (Figs. 21 and 22). Within the GHF, superior acces- through or over. Gaudomedial branches may arise distal
sory arteries behave exactly like a rostrolateral branch to their usual site, e.g., at the base of the seventh nerve
of AlGA, bifurcating into typical ascending and de- or anterior to the flocculus, and describe aberrant
scending arteries (%) (Fig. 21), or passing without sig- courses antero-inferior or lateral to the flocculus prior
nificant bifurcation directly into the posterolateral fis- to reaching their ultimate distribution. Entire arteries
sure as typical descending arteries (%) (Fig. 23). Angio- may be postfixed. Arteries may even arise which ap-
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 371 Neuroradiology

Fig. 24. Arterial-venous correlation; vein of the lateral

recess. A. Lateral projection; arterial phase. "AICA" plus
inferior accessory artery. The inferior accessory artery (lAC)
anastomoses with PICA (=$=).
B. Lateral projection; venous phase. The vein of the later-
al recess (VLR) and its peduncular, 1, floccular, 2, and su-
prafloccular, 3, segments are shown. The suprafloccular seg-
ment runs over the flocculus and onto the brachium pontis to
reach the petrosal vein (PV) at or just lateral to the anterior
angle.
C. Composite diagram. The suprafloccular segment of
the VLR falls between the portions of the marginal artery
(MA) on the anterolateral margin and the suprafloccular seg-
ment of the rostrolateral artery on the brachium pontis. The
floccular segment of the VLR, 2, falls over the descending
branch (DA) of the rostrolateral artery. Both the genu of the
marginal artery and the petrosal vein mark the approxlrnate
site of the anterior angle. Were it visualized, the artery of the
lateral recess would lie adjacent to the VLR, 1.

pear to have little other function than to pass postero- lateral branches of AICA (7). in this paper we have fol-
inferolaterally to anastomose with other segments of lowed the anatomic nomenclature of Atkinson (1). In
AICA or PICA. In general however, the features of AICA plate lIa of his work, he clearly illustrates the bifurca-
are sufficiently constant to be identifiable on subtracted tion of AICA into its two typical branches designated
direct 2X magnification angiograms. medial and lateral. We have added the prefixes rostro
and caudo to emphasize that the RL lies generally supe-
DISCUSSION rior as well as lateral to the CM. We feel that the
branch of the RL which passes superiorly into the GHF
The nomenclature of the branches of AICA has dif- should be called the ascending artery and that the
fered from author to author (1, 6, 14, 23). Some have branch of the RL which passes inferiorly along the ant-
considered the main bifurcation of AICA to be the divi- ero-inferomedial aspect of the biventral lobule and bi-
sion of the RL into its ascending and descending ventral ridge should be called the descending artery
branches, called by them the lateral and medial arte- (composed of retrofloccular and biventral segments). In
ries, respectively (23, 24, 26). These authors have de- terms of this nomenclature, the bifurcation of AICA into
scribed the AICA bifurcation as occurring immediately its rostrolateral and caudomedial branches then occurs
proximal or distal to the seventh and eighth nerves (25) on or a few millimeters lateral to the sixth nerve in most
and appear to consider the eM a variable anastomotic cases, and the bifurcation of the RL into its ascending
channel to PICA. Other authors have called proximal and descending arteries occurs above the flocculus dis-
and distal portions of an enlarged CM the medial and tal to the eighth nerve in most cases.
372 THOMAS P. NAIDICH AND OTHERS May 1976

Fig. 25. Arterial-venous correlation; vein of the lateral

recess. A. Towne's projection; arterial phase. The rostro-
lateral artery forms a prominent superomedial loop, (Bl,
SFR), outlining the position of the brachium pontis and the
top of the flocculus (F).
B. Towne's projection, venous phase. Peduncular, 1, floc-
cular, 2, and suprafloccular segments, 3, of the vein of the
lateral recess (VlR) are well seen.
C. Composite diagram. The suprafloccular segment of
the VlR superimposes on the suprafloccular segment of the
rostrolateral artery. The floccular segment projects beneath
the suprafloccular segment of the rostrolateral artery. In most
cases at least the suprafloccular portions of both artery and
vein are superimposable.

The majority of the vessels discussed are readily de- CONCLUSION

tected angiographically, as we have shown. Some of
the smaller vessels are visualized less frequently. To We have demonstrated that AICA can be visualized
date, there has been difficulty in recognizing the de- routinely in lateral projection in well-penetrated, sub-
scending artery in frontal projection although on occa- tracted magnification radiographs. Familiarity with its
sion (Fig. 14, B) it may be demonstrated. The artery of detailed anatomy in this projection permits identification
the lateral recess and the choroidal blush of the lateral of the belly of the pons, pontomedullary sulcus, supra-
recess have not yet been identified in situ unequivocal- olivary fossette, 5th, 6th, 7th, 8th, 9th, 10th, and 11th
ly, although we believe now that what has been called cranial nerves, flocculus, brachium pontis, great hori-
the "medullary blush" (5, 13) in some cases really rep- zontal and posterolateral fissures, superior semilunar,
resents contrast within the choroid plexus of the lateral inferior semilunar, and biventral lobules of the cerebel-
recess. In some cases with good filling there is diffi- lum.
culty in determining the configurations and laterality of ACKNOWLEDGMENTS: We wish to express our deepest thanks to
superimposed left and right AICA loops. Ms. Linda Michaels, Ms. Evelynne Shaw, Mr. George Ozaki, Mr.
Vol. 119 THE NORMAL ANTERIOR INFERIOR CEREBELLAR ARTERY 373 Neuroradiology

Jean-Pierre Lahary, and Dr. John Pearson for their assistance in pre- 13. Huang YP, Wolf BS: Angiographic features of fourth ventri-
paring this paper. cle tumors with special reference to the posterior inferior cerebellar
artery. Am J Roentgenol 107:543-564, Nov 1969
14. Huang YP, Wolf BS: Angiographic features of brain stem
tumors and differential diagnosis from fourth ventricle tumors. Am J
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