Surg Neurol

1988;30:3-59

Microsurgical Anatomy of the Choroidal Fissure

Shinji Nagata, M.D., Albert L. Rhoton, Jr., M.D., and Margaret Barry, M.A.
Department of Neurological Surgery, University of Florida College of Medicine, Gainesville, Florida

Nagata S, Rhoton AL Jr, Barry M. Microsurgical anatomy of the

choroidal fissure. Surg Neurol 1988;30:3-59.

The microsurgical anatomy of the choroidal fissure was

examined in 25 cadaveric heads. The choroidal fissure,
the site of attachment of the choroid plexus in the lateral
ventricle, is located between the fornix and thalamus in
the medial part of the lateral ventricle. The choroidal
fissure is divided into three parts: (a) a body portion
situated in the body of the lateral ventricle between the
body of the fornix and the thalamus, (b) an atrial part
located in the atrium of the lateral ventricle between the
crus of the fornix and the pulvinar, and (c) a temporal part
situated in the temporal horn between the fimbria of the
fornix and the lower surface of the thalamus. The three
parts of the fissure are the thinnest sites in the wall of the
lateral ventricle bordering the basal cisterns and the roof
of the third ventricle. Opening through the body portion
of the choroidal fissure from the lateral ventricle exposes
the velum interpositum and third ventricle. Opening
through the temporal portion of the choroidal fissure
from the temporal horn exposes the structures in the
ambient and crural cisterns. Opening through the atrial
portion of the fissure from the atrium exposes the quadrigeminal cistern, the pineal region, and the posterior
portion of the ambient cistern. The neural, arterial, and
venous relationships of each part of the fissure are reviewed. The operative approaches directed through each
part of the fissure are also reviewed.
KEYWORDS: Choroidal fissure; Lateral ventricles; Third Ventricle; Subarachnoid cisterns; Microsurgical anatomy

The choroidal fissure is a narrow cleft in the medial part

of the lateral ventricle. It is formed at about 8 weeks of
embryonic development when the vascular pia mater
that forms the epithelial roof of the third ventricle
invaginates into the medial wall of the cerebral hemisphere. No nervous tissue develops between the ependyma and pia mater along this invagination that forms
the choroidal fissure, thus creating the thinnest site in
Address reprint requests to: Albert L. Rhoton,Jr., M.D., Department
of Neurosurgery, Box J-265, JHMHC, Gainesville, Florida 32610.
Received February 4, 1988; accepted February 12, 1988.

1988 by ElsevierSciencePublishingCo., Inc.

the wall of the lateral ventricle. Opening through the

fissure from the lateral ventricle during intracranial
operations provides access to several structures that are
difficult or impossible to expose through the extracerebral route.
Materials and Methods
In this study, data was collected from 25 cadaveric
heads. Colored latex or silicone was injected into the
arteries and veins to facilitate the dissections. The
measurements in Tables 1 and 2 were taken from these
specimens.
Results

General Considerations
Neural, Ventricular, and Cisternal Relationships. The
choroidal fissure is the site of attachment of the choroid
plexus in the lateral ventricle (Figures 1 and 2). When
the choroid plexus of the lateral ventricle is torn away,
the fissure is seen as a narrow cleft situated between the
fornix and the thalamus in the medial part of the lateral
ventricle. The fissure extends in a C-shaped arc from the
foramen of Monro through the body, atrium, and
temporal horn of the lateral ventricle. Its inferior
termination, called the inferior choroidal point, is located immediately behind the uncus and beside the
lateral geniculate body.
The thalamus forms the central core around which
the choroidal fissure wraps. The fissure extends around
the superior, inferior, and posterior surfaces of the
thalamus. The thalamus is situated so that the part of its
surface lateral to the choroidal fissure forms part of the
wall of the lateral ventricle, and the part medial to the
fissure forms part of the wall of the third ventricle or
basal cisterns.
The fornix is another C-shaped structure like the
choroidal fissure. It forms the outer circumference o f
the choroidal fissure. The fornix consists mainly of
hippocampomamillary tract fibers that originate from
the hippocampus, subiculum, and der~tate gyrus of the
temporal lobe. The initial part of the !fornix, called the
fimbria, arises in the floor of the temporal horn on the
0090-3019/88/$3.90

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Table 1. Distance Between the Choroidal Fissure and Selected Structures

(Measured in the Horizontal Plane)

A-B
B-C
A-D'
D-D'
E-E'
F-F'
B-K
B-B'
G-G'
B-G
C-I
I-J
C-L
C-H

Average (ram)

Range (ram)

33.5
21.1
5.7

25.0-41.0
15.5-27.0
3.0-10.0
2 . 0 - 8.5
3.0-13.0
3.0-14.5
29.0-45.2
18.0-25.5
5.5-17.0
17.0-30.0
29.5-48.5
21.0-32.0
2 . 0 - 7.0
15.0-23.2

4.2
7.2
10.8
38.2
22.8
12.6
23.8
40.1
28.0

4.6
19.4

Key:
A Posterior edge of the foramen of Monro
B Posterior end of the atrial part of the choroidal
fissure
B' Point at which a line directed medially from B
crosses the midline
C Site of entry of the anterior choroidal artery into the
temporal horn
D Point on midline directly above the center of the
massa intermedia
D' Point at which a line directed laterally from D
crosses the choroidal fissure.
E Point in midline on the floor of the third ventricle at
midpoint between D and F
E' Point that a horizontal line beginning in midline
above point E intersects the body portion of the
choroidal fissure
F Anterior end of the posterior commissure in midline

P' Point that a horizontal line beginning in midline

above point F intersects the choroidal fissure
G Anterior end of the habenular commissure
G' Point that a horizontal line beginning in the midline
above point G intersects the choroidal fissure
H Origin of the anterior choroidal artery from the
carotid artery
1 Anterior end of the temporal lobe
J Anterior end of the temporal horn of the lateral
ventricle
K Posterior end of the sylvian fissure
L Lateral edge of the cerebral peduncle

ventricular surface of the hippocampal formation and

passes posteriorly to become the crus of the fornix.
Each crus wraps around the posterior surface of the
pulvinar of the thalamus and arches superomedial toward the lower surface of the splenium of the corpus
callosum. At the junction of the atrium and the body of
the lateral ventricle, the paired crura meet to form the

body of the fornix, which runs forward along the

superomedial border of the thalami. The body of the
fornix separates the roof of the third ventricle from the
floor of the bodies of the lateral ventricles. At the
anterior margin of the thalamus, the body of the fornix
divides into two columns which arch around the superior and anterior margins of the foramen of Monro in

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Table 2. Distance Between the Body Portion of the Choroidal

Fissure and Structures in the Third Ventricle
Average (mm)

Range (ram)

5.9
6.7
12.3
14.4
18.8
16.8
15.8

5 . 5 - 7.0
5 . 5 - 7.5
10.0-15.0
12.0-17.5
16.0-22.0
13.0-20.0
11.0-19.0

A-B
A-C
A-D
A-E
A-F
G-H
l-J

Key:
A Point on choroidal fissure above center of massa intermedia
B Internal cerebral vein
C Stria medullaris thalami
D Center of the massa intermedia
E Sulcus limitaus
F Floor of the third ventricle
G Point on choroidal fissure above anterior edge of the posterior commissure
H Anterior edge of the posterior commissure
I Point on choroidal fissure above anterior edge of the habenular commissure
J Anterior edge of the habenular commissure

their course toward the mamillary bodies. In the area

below the splenium of the corpus callosum, a thin sheet
of fibers interconnect the medial margins of the crura to
form the hippocampal commissure. The body of the
fornix is located in the medial part of the body of the
lateral ventricle; the crus of the fornix is in the medial
part of the atrium; and the fimbria of the fornix is in the
medial part of the temporal horn. The body of the
fornix crosses the thalamus approximately half-way
between the medial and lateral edge of the superior
surface of the thalamus: the part of the thalamus lateral
to the body of the fornix forms the floor of the body of
the lateral ventricle and the part medial to the fornix
forms part of the wall of the velum interpositum and
third ventricle. The crus of the fornix crosses the
pulvinar approximately midway between the medial and

lateral edge of the pulvinar: the part of the pulvinar

lateral to the crus of the fornix forms part of the anterior
wall of the atrium and the part medial to the fornix
forms part of the anterior wall of the quadrigeminal
cistern. The fimbriae of the fornix passes below the
inferolateral part of the thalamus just lateral to the
medial and lateral geniculate bodies. The part of the
thalamus medial to the fimbria forms the roof of the
ambient cistern.
The lateral ventricles, in which the Choroidal fissures
are situated, are also C-shaped structures that wrap
around the thalami. Identifying the ch0roidal fissure in
the medial part of the ventricles requires an understanding of the structures forming each of Ithe walls of the
ventricles. Each lateral ventricle has five parts: the body,
atrium and frontal, temporal, and occipital horns. Each
of these five parts have medial and lateral walls, a roof,
and a floor. In addition, the frontal and temporal horns
and the atrium have anterior walls. The walls of the
lateral ventricles are formed predominately by the
thalami, septum pellucidum, corpus callosum, caudate
nuclei, and fornix.
The choroid plexus in each lateral ventricle has a
C-shaped configuration that parallels its site of attachment to the choroidal fissure. The choroid plexus from
each lateral ventricle extends througll the foramen of
Monro and is contiguous with the paired parallel strands
of choroid plexus that are attached tO the roof of the
third ventricle. In the atrium, the cho~oid plexus forms
a prominent triangular tuft called the g~omus. The edges
of the thalamus and fornix borderir~g the choroidal
fissure have small ridges, called the ta~niae, that anchor
the choroid plexus to fornix and thal~tmus. The teniae
on both the forniceal and thalamic side of the fissure are
composed of two layers, one of ependyma and one of
pia mater. The tenia on the thalamic Side is called the
tenia choroidea. The tenia on the forniceal side of the
fissure is called the tenia fornicis except in the temporal
horn where it is referred to as the tenia fimbriae.
Arterial Relationships. The arteries most intimately
related to the choroidal fissure are ihe choroidal arteries, and the trunks and branches o f the posterior
cerebral artery that pass through tl~e basal cisterns
(Figure 3) [8,33].
The choroidal'arteries supply the Choroid plexus in
the lateral and third ventricles. They arise from the
internal carotid and posterior cerebrkl arteries in the
basal cisterns and reach the choroid plexus by passing
through the choroidal fissure. The choroidal arteries are
divided into the anterior and posterior choroidal arteries. The posterior choroidal arteries consist of lateral
and medial groups called the lateral and medial posterior choroidal arteries. Each of the choroidal arteries

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Nagata et al

Figure 1. Neural relationships. (A) The upper part of the cerebralhemispheres has been removed. The choroidalfissure (Chor. Fiss.), the site of attachment
of the choroid plexus (Chor. Plex.), is situated between the fornix and thalamus. Structures exposed in the frontal horn (Front. Horn), body (Body Lat.
Vent.), atrium and t ~ r n
(Temp. Horn) of the lateral ventricle include the caudate nucleus (Caudate Nucl.), corpus callosum (Corp.-~--,--,--,--,-~,
-h-~campal formation (Hippo.), and Joramen of Monro (For. of Monro). Other structures in the exposure include the frontal (Front. Lobe), parietal (Par.
Lobe), temporal (Temp. Lo-~, and occipital lobes (Occip. Lobe), globus pallidus (Glob. Pall. ), and calcarine sulcus (Calc. Sulc. ). ( ~ d
view of t h e - ~
~eral ventricle. ~ d
plexus has been ronove-~l-by-~aching it along t h ~ f i s s u r e .
In the body of t ~ e n t r i c l e
the choroidal fissure is
situated between the body of the fornix and the thalamus; in the atrium it is situated between the crus of the fornix and the pulvinar of the thalamus; and in
the temporal horn it is situated between the fimbria of the fornix and the inferolateral surface of the thalamus. Other structures in the exposure include the
collateral trigone (Coll. Trig.) and eminence (Coll. Emin.) and the septum pellucidum (Sept. Pell. ).

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1988;30:3-59

i~ "~

~'~

~,~i ~ ~

I~ ~.~

~- ~

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1988;30:3-59

Nagata et al

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1988~30:3-59

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Figure 1. (I) Superolateral view into the quadrigeminal cistern. This cistern is located between the atrial portion of the paired choroidalfissures. (J) The
part of the thalamus above the temporalportion of the choroidalfissure has been removed. The section extends through the lateral part of the cerebralpeduncle
(Ped.). The crural cistern (Crural C ist.) is located between the uncus and cerebralpeduncle. The ambient cistern (Ambient C ist.) is located medial to the
a~'~ate gyrus and the rounded medial edge of the parahippocampal gyrus called the subiculum.

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11

Figure 1. (K) Enlarged view. The ambient and crural cisterns are situated medial to the temporalportion of the choroidalfissure. The tenia fimbriae is the
site of attachment of the choroidplexus on the forniceal side of the choroidalfissure. (L) Medial surface of the choroidalfissure and cerebralhemisphere. The
choroidalfissure extendsfrom the foramen of Monro around the thalamus to the inferior choroidalpoint. (Inf. Chor. Point) which is loeated behind the uncus
near the lateral geniculate body (Lat. Gen. Body). The atrial portion of this fissure is situated in the wall of the quadrigeminal cistern and the temporal
portion is located in the wall of the ambient cistern. The body of the fornix has been removed. The structures in the wall of the third ventricle include the
anterior (Ant. Comm.), posterior, and habenular commissures (Hab. Comm.), mamillary bodies (Mare. Body), lamina terminalis (Lam. Term.), and
pituitary stalk (In~und. ).

12

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1988;30:3-59

give off branches to the neural structures along its

course. The most common pattern is for the anterior
choroidal arteries to supply a portion of the choroid
plexus in the temporal horn and atrium; the lateral
posterior choroidal arteries to supply a portion of the
choroid plexus in the atrium, body, and the posterior
part of the temporal horn; and the medial posterior
choroidal arteries to supply the choroid plexus in the
roof of the third ventricle and part of that in the body of
the lateral ventricle. The size of the plexal areas supplied by the anterior and posterior choroidal arteries is
inversely related: as the area supplied by one artery
enlarges, the area supplied by the other decreases. The
same inverse relationship occurs between the areas
supplied by the lateral and medial posterior choroidal
arteries. The lateral and medial posterior choroidal
arteries arising on one side may infrequently send
branches through the choroidal fissures to the choroid
plexus in the opposite lateral ventricle.

Venous Relationships. The veins related to the choroidal fissure are those that course in the walls of the
lateral ventricles, the roof of the third ventricle and the

Nagata et al

basal cisterns bordering the tentorial incisura. The veins

that course in the walls of the lateral ventricles arise in
the deep white and gray matter and course in a subependymal location toward the choroidal fissure (Figure 4).
After passing through the fissure they course in the roof
of the third ventricle and basal cisterns and empty into
the internal cerebral, basal, and great veins. The veins
draining the frontal horn and body of the lateral ventricle pass through the choroidal fissure to empty into the
internal cerebral vein, those draining the temporal horn
pass through the choroidal fissure to empty into the
basal vein, and the veins from the atrium pass through
the choroidal fissure to empty into the segments of the
basal, internal cerebral, or great veins that are medial to
the atrium.
The ventricular veins are divided into medial and
lateral groups based on whether they course through
the thalamic or forniceal side of the choroidal fissure.
The lateral group passes through the thalamic or inner
side of the fissure and the medial group passes through
the outer or forniceal circumference of the fissure. The
veins comprising the medial and lateral groups frequently join near the choroidal fissure to form a corn-

A
Figure 2. Cisternal and ventricular relationships of the temporal and atrial portions of the choroidalfissure. (A) Left lateral view. The left temporal lobe
(Temp. Lobe) has been elevated to expose the ambient (Ambient Cist.), crural (Crnral Cist. ), and quadrigeminal cisterns (Quad. Cist. ). The crural cistern is
~---di'af-ff~e uncus and the ambient cistern is medial to the parahippocampal gyrus (Parahippo. Gyr.). Structures located in the walls of the basal cisterns
include the anterior perforated substance (Ant. Perf. Subst.), olfactory (Olf. Tr.) ana optic tracts (Optic Tr.), mamillary bodies (Mare. Body), cerebral
penduncle (Ped. ), lateral (Lat. Gen. Body) and medial geniculate bodies ( ~ e n .
Body), lateral m ~ i c
(Lat. Mes. Sulc.) and pontomesencephalic
sulci (Pon. Mes. Sulc.), and the superior (Sup. Coll.) and inferior colliculi (Inf. Coll.). The tentorial edge (Tent. Edge) grooves (Tent. Groove) the lower
surface of the uncus. Other structures in t ~ e
include the oculomotor nerve (II__I),carotid artery ( C a r ~ t e n t o r i u m
(Tent.).

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13

14

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1988;30:3-59

Nagata et al

Figure 2. (D) The dentate and parahippocampal gyri have been removed to expose the temporal horn (Temp. Horn). The fimbria of the fornix has been
preserved. The tapetum of the corpus callosum is in the roof of the temporal horn. The choroidplexus (Chor. Plex.) is attached along the choroidalfissure. (E)
The fimbria of the fornix has been removed. A short segment of choroidplexus has been removedand ~ e
has been elevated with a forceps in order to
show the tenia choroidea and tenia fimbriae, the fine membranes to which the choroid plexus attaches on the thalamic and forniceal sides of the fissure.

Choroidal Fissure

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15

Figure 2. (F) The tenia fimbriae has been retracted laterally to show the line of attachment of the tenia choroidea to the surface of the pulvinar along the
stria to~ainalis (Stria Term.). (G) The tenia fimbriae and the choroidalplexus have been removed but the tenia choroidea and its s~te of attachment to the
pulvinar has been preserved. The tail of the caudate nucleus (Tail Caudate NucL ) is located in the roof of the temporal horn )~ust lateral to the stria
terminalis.

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Nagata et al

Body
ial Portion
Horn

The
Front.
Ant.C
Pos

y Portion
Chor. Hss.Temlc

It.

Lat. Pos

r.A.

Portion

,ody Portion
Atrial Portion
F
Med. Po

.Chor.A.
,rn

Chor. Fiss."

A.

Figure 3. Arterial relationships of the choroidalfissure. Lateral (top), superior (middle), and anterior (bottom) views. The choroidalfissure is located
between the thalamus (yellow) and fornix (blu___e).The choroidalarteri-~-which s u p p l y ~ o r o i d plexus in the--~y (Body Lat. Vent.), atrium and temporal
horn (Temp. Horn) of ~ e r a l
ventricle pass through the choroidalfissure. The choroidalfissure is divided into a body portion (C hor. Fiss. Body Portion)
located in the body of the lateral ventricle, an atrial portion (Chor. Fiss. Atrial Portion) located in the atrium, and a temporal portion (Chor. Fiss. Temp.
Portion) located in the temporal horn. The choroidalfissure does not extend into the frontal (Front. Horn) or occipital horns (Occip. Horn). The anterior
~ l
arteries (Ant. Chor. A. ) arise from the internal carotid artery (Car. A.) and enter the anterior ~Oartof the temporal horns. The medial posterior
choroidal arteries (Med. Post. Chor. A. ) arisefrom the proximal part of the posterior cerebralarteries (P.C.A. ), encircle the brainstem below the thalami, and
pass forward in the roof of the third ventricle, where they give branches to the choroidplexus in the r o o ~ the third ventricle and the bodies of the lateral
ventricles. The lateral posterior choroidal arteries (Lat. Post. Chor. A. ) pass through the choroidalfissures to supply the choroidplexus in the atria and bodies
of the lateral ventricles. Other structures in the illustration include the middle (M.C.A. ) and anterior cerebral(A.C.A. ) and posterior communicating arteries
(Post. Comm. A.), and the hippocampal formation (Hippo.).

Choroidal Fissure

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17

rial POrtion
lien

A
US

~0

Tran
Chor. Fiss.Tem
Po:

V.
dy PortiOn
al Portion

Chor
Chor. F
Chor.

Figure 4. Venous relationships of the choroidalfissure. Lateral (top), superior (middle), and anterior (bottom) views. The choroidalfissure is locatedbetween
the thalamus (yellow) and the fornix (red). The choroidalfissure--~divided into a-a'-b~yportion (Chor. Fiss. Body Portion) located in the body of the lateral
ventricle, an a ~ o r t i o n (Chor. Piss.--Atrial Portion) located in the atrium and a temporalportion (Chor. Fiss. Temp. Portion) located in the temporal
horn. The veins draining the walls of the frontal (Front. Horn), temporal (Temp. Horn), and occipital horns (Occip. Horn), atrium, and body of the lateral
ventricle (Body Lat. Vent. ) pass through the margins of the choroidalfissure and drain into the internal cerebral(Int. Cer. V. ), basal (Basal V. ), and great
veins (V. Galen). The veins passing through the fissure are divided into medial and lateral groups. The lateral group consists of the anterior caudate vein
(Ant: ~ )
in the frontal horn; the thalamostriate (Thai. Str. V. ), thalamocaudate (Thal. Caud. V. ), and posterior caudate veins (Post. Caud. V. ) in
the body; the lateral atrial veins (Lat. Atr. V. ) in the atrium; ~
inferior ventricular ilnf Ven. V. ) and amygdalar veins (Amygd. I/. ) in the temporal
horn. The medial group is formed by the anterior septal vein (Ant. Sept. V. ) in the frontal horn, the posterior septal veins ( P o s ~ )
in the body, the
medial atrial veins (Med. Atr. V. ) in the atrium, and the transverse hippocampal veins (Trans. Hippo. V. ) in the temporal horn.[The superior choroidal
veins (Sup. Chor. V. ) drain into the thalamostriate and internal cerebral veins, and the inferior choroidal veins (Inf.. Chor. V. ) drain into the inferior
ventricular or basal veins. The vein of Galen drains into the straight sinus (Str. Sinus).

18

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Nagata et al

mon stem before terminating in the internal cerebral,

basal or great veins.
During operations on the lateral ventricles the veins
more commonly provide orienting landmarks than the
arteries since the arteries in the ventricular walls are
small and poorly seen but the veins are larger and are
visible through the ependyma. These venous landmarks
are especially helpful in the presence of hydrocephalus
where the normal angles between the neural structure
disappear.

Parts of the Choroidal Fissure

This choroidal fissure is divided into three parts: (a) a
body portion situated in the body of the lateral ventricle
between the body of the fornix and the thalamus; (b) an
atrial part located in the atrium of the lateral ventricle
between the crus of the fornix and the pulvinar; and (c) a
temporal part situated in the temporal horn between the

fimbria of the fornix and the lower surface of the

thalamus (Figures 1, 2, 5, and 6). The three parts of the
fissure are the thinnest sites in the wall of the lateral
ventricle bordering the basal cisterns and the roof of the
third ventricle.

Body Portion of the Choroidal Fissure

Neural Relationships. The body portion of the choroidal fissure is situated in the body of the lateral
ventricle between the body of the fornix and the
superior surface of the thalamus (Figures 1, 5, and 6).
The velum interpositum through which the internal
cerebral veins course is located on the medial side of the
body portion of the fissure in the roof of the third
ventricle. Opening through the choroidal fissure from
the body of the ventricle will expose the velum interpositum and the roof of the third ventricle.
The body portion of the choroidal fissure is related to

Figure 5. Relationship of the choroidalfissure to the thalamus and the lateral and third ventricles. Anterior views. (A) The anterior part of the left frontal
lobe (Front. Lobe) has been removed to expose the frontal horn (Front. Horn). The choroidalfissure (Chor. Fiss.) and choroid plexus (Chor. Plex.) extends
backw~he
foramen of Monro (For. Monro). The frontal horn is bounded by the corpus callosu--m-~o-~.-Call.), septum pellucidu-~Se~. Pell. ), and
caudate nucleus (Caudate Nucl. ). Other structures in the exposure include the optic nerve (Optic N. ), c a ~
A. ) and anterior ( A . C ~ m i d d l e
cerebral arteries (M.C.A.), and the internal capsule (Int. Cap.).

Choroidal Fissure

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~i~

~.~I
~. ~

~-.~

~ "~'

~ ~FI~

~ ~.~

~ , ~ L ~

19

20

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1988;30:3-59

Nagata et al

Figure 5. (D) Enlarged view of the section through the temporal horn. The choroid plexus is attached to the tenia choroidae and the tenia fimbriae. The
anterior choroidal artery passes through the choroidal fissure to reach the temporal horn. Other structures in the exposure include the basal vein (Basal V. ),
lateral geniculate body (Lat. Gen. Bod~), hippocampal formation (Hippo.), parahippocampal gyrus (Parahippo. Gyr.), collateral eminence (Co~ Emin.),
and collateral sulcus (Coll. Sulc.). (E) The section has been e x t e n d ~ a r d
past the mamillary bodies (Mare. Body) to the level of the posteri-o-'-rpart-'io~he
third ~entricle and t ~ M e d .
Gen. Body) and lateral geniculate bodies.

Choroidal Fissure

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21

Figure 5. (F) Enlarged view. The lower layer of the tela choroidea in the roof of the third ventricle attaches to the dorsal surface *f the pineal body. The
suprapineal recess is located between the tda and the upper surface of the pineal body. The pineal recess is situated between the haben~lar (Hab. Comm.) and
posterior commissures. The section extends through the habenular nuclei (Hab. Nucl.) (G) Anterior superior view of the same specimen. The posterior cerebral
artery arises from the basilar artery (Bas. A.) in the interpeduncular ciste-'m~~ d .
Cist.) and passes around the cerebralpeduncle~nd through the crural
(Crural Cist.) to reach the ambient cistern (Ambient Cist.). The medial posterior cboroidal artery (Med. Post. Chor. A.) arises from ~heproximal part of the
posterior cerebral artery. Lateral posterior choroidal arteries (Lat. Post. Chor. A.) arise from the posterior cerebral artery in the ambient cistern and enter the
temporal horn. The inferior ventricular vein (Inf. Vent. V.) empties into the basal vein.

22

Surg Neurol
1988;30:3-59

Nagata et al

~I'~
~
~ ~I~
~.,i~ v
~.~

~,~I

~ ~

~,

~ ~ ~I.~
~
~F ~
~,,,~
I~.

. ~ . ~ _ _ ~ ~ ..~ ~ ~,
~"~
~ ~ ~ 1 ~

Surg Neurol
1988;30:3-59

Choroidal Fissure

.~

~'~

..~

. ~ ~..:
~.~ ~

.~

~~

~~

'~.~

,~ ~ 1 ~

".~

~ "~

~.~ ,.~1~ ~ , . ~
U'~
~

~ .' ~~
~

~(

~ '' ~
~
'~

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23

24

~L ~h~
~

Choroidal Fissure

Surg Neurol
1988;30:3-59

25

Figure 6. (G)The crosssection has been extendedforward to the caudal edge of the uncus. The body of the choroidalfissure is situated between the body of the
fornix and the upper surface of the thalamus. The temporalpart of the choroidalfissure extends backwardfrom the posterior margin ~ the uncus. The section
extends through the lenticular (Lent. Nucl.), subthalamic (Subthal. Nucl.) and amygdaloid nuclei (Amygd. Nucl.), and the optie tract (Optic Tr.). (H)
Enlarged view of the section t h r o ~ y
of the lateral ventricle. The choroidplexus is attached along the choroidalfissure to the tenia c ~ n d
the
tenia fornicis.

26

Surg Neurol
1988;30:3-59

Nagata et al

Figure 6. (I) Enlarged view of the section through the temporal horn. The choroidalfssure is located between the teniae fimbriae and the teniae choroidea.
The anterior choroidal artery (Ant. Chor. A.) passes through the crural cistern (Crural Cistern) and enters the temporal horn by passing through the
choroidalfissure near the inferior choroidal point.

the frontal horn and body of the lateral ventricle. The

frontal horn is the part of the lateral ventricle located
anterior to the foramen of Monro. The choroidal fissure
does not extend into the frontal horn, however, some
operative approaches to the superior part of the choroidal fissure are directed through the frontal horn. The
medial wall of the frontal horn is formed by the septum
peUucidum, the anterior wall by the genu of the corpus
callosum, the lateral wall by the head of the caudate
head, and the narrow floor by the rostrum of the corpus
callosum. The columns of the fornix, as they pass
anterior to the foramen of Monro are in the posteroinferior part of the medial wall of the frontal horn.
The body portion of the choroidal fissure is located
in the body of the lateral ventricle. This part of the
lateral ventricle extends from the posterior edge of the
foramen of Monro to the point where the septum
pellucidum disappears and the corpus caUosum and
fornix meet. The roof is formed by the body of the
corpus callosum, the medial wall by the septum pellucidum above and the body of the fornix below, the
lateral wall by the body of the caudate nucleus, and the
floor by the thalamus. The caudate nucleus and thalamus are separated by the striothalamic sulcus, the
groove in which the striae terminalis and the thalamostriate vein course.

The close relationship of the internal capsule to the

choroidal fissure and the lateral wall of the frontal horn
and body of the lateral ventricle is often forgotten in
planning operative approaches through the ventricles
and choroidal fissure. The anterior limb of the internal
capsule, which is located between the caudate and
lentiform nuclei, is separated from the frontal horn by
the head of the caudate nucleus, and the posterior limb,
which is situated between the thalamus and the lentiform nucleus, is separated from the body of the lateral
ventricle by the thalamus and body of the caudate
nucleus. However, the genu of the internal capsule
comes directly to the ventricular surface, and touches
the wall of the lateral ventricle immediately lateral to
the foramen of Monro in the interval between the
caudate nucleus and the thalamus.
The velum interpositum is the space on the medial
side of the body portion of the choroidal fissure through
which the internal cerebral veins course (Figures 7 and
8). It is located in the roof of the third ventricle below
the body of the fornix, and between the superomedial
surfaces of the thalami. The veins draining the frontal
horns and bodies of the lateral ventricles pass through
the margins of the choroidal fissures and converge on
the velum interpositum where they join to form the
internal cerebral veins. The velum interpositum is usu-

Choroidal Fissure

Surg Neurol
1988~30:3-59

27

Figure 7. Vascular relationships. Body of the choroidalfissure. (A) Midsagittal section. The internal cerebralveins (Int. Cer. V.) ~hat course in the velum
interpositum (Vel. Interpos.) and the basal veins (Basal V.) that course in the crural (Crural Cist.) and ambient cisterns (Ambient Q'st. ) empty into the vein
of Galen (V. o] Galen) in the quadrigeminal cistern (Quad. Cist.). The posterior cerebralartery (P.C.A.) courses through the ambient and quadrigeminal
cisterns. Other structures in the exposure include the third ventricle (3 Vent.), corpus callosum (Corp. Call.), pituitary stalk (Infund.), cerebralpeduncle
(Ped.), septum pellucidum (Sept. Pell.) and the carotid (Car. A.), anterior cerebral(A.C.A.), callosomarginal(Call. Marg. A.) and p$ricallosalarteries (Peri.
of the tela c h o r o i ~ e l a ) that forms the up--ffff~all of the velum interpositum is adherent t$ the lower surface
Ca---~.A.). (B) Enlarged v i ~ e r
b-~-y~ t h e fornix. The layer of the tela choroidea that forms the lower wall of the velum interpositum is attached along the stria me~tullaris thalami (Stria.
Med. Thal.) and the upper surface of the pineal body. The choroidplexus (Chor. Plex.) hangs down from the lower layer of the tela choroidea into the th--ff~-~r
ventric-~e. The posterior cerebralartery gives rise to the occipitotemporal(Occip. Temp. A.), parietooccipital (Par. Occip. A:), and calcurine (Calc. A.) arteries
in the quadrigeminal cisterns. The anterior choroidal artery (Ant. Chor. A.) arisesfrom the carotid artery. Other structures in the exposure include the optic
nerve (Optic N. ), foramen of Monro (For. Monro), anterior commissure (Ant. Comm.), and mamillary bodies (Mam. Body).

28

Surg Neurol
1988;30:3-59

Nagata et al

Figure 7. (C) Enlarged view of the velum interpositum and roof of the third ventricle. The pineal recessis located between the habenular (Hab. Comm.) and
posterior commissures (Post. Comm.), and the suprapineal recessis located between the lower layer of tela choroidea and the pineal body. (D) The body of the
fornix bordering the right choroidalfissure (Chor. Fiss.) has been removedbut part of the tenia fornicis has beenpreserved. Branches of the medial (Med. Post.
Chor. A.) and lateral posterior choroidal arteries (Lat. Post. Chor. A. ) coursearound the thalamus and through the velum interpositum and c h o r o ~
to reach the choroidplexus. The anterior caudate (Ant. Caud. V. ), anterior septal (Ant. Sept. V. ), and thalamostriate veins (Thal. Str. V. ) join the internal
cerebral vein. Other structures in the exposure include the caudate nucleus (Caudate Nucl.), lateral ventricle (Lat. Vent. ) and lamina terminalis (Lain.
Term.).

Choroidal Fissure

Surg Neurol

1988;30:3-59

29

30

Surg Neurol
1988;30:3-59

Nagata et al

' ~

~ "~,~~

"~1,,~1..~
~ ~1 "",

"~ ,~~1.~1~

',J

Choroidal Fissure

ally a closed space that extends from the foramen of

Monro to the area immediately above the pineal body.
It tapers to a narrow apex just behind the foramen of
Monro. It may infrequently communicate between the
splenium and the pineal body with the quadrigeminal
cistern to form the cisterna velum interpositum. The
upper and lower walls of the velum interpositum are
formed by the two membranous layers of tela choroidea
in the roof of the third ventricle. The upper wall is
formed by the layer of tela choroidea that is attached to
the lower surface of the body of the fornix and the
hippocampal commissure. The lower wall is formed by a
layer of the tela choroidea that attaches to the small
ridges called taenia thalami on the free edge of the striae
medullaris thalami. The latter are paired fiber tracts that
extend along the superomedial border of the thalami
from the foramen of Monro to the habenular commissures. The posterior edge of the lower layer of tela
choridea is attached to the superior surface of the pineal
body. The suprapineal recess of the third ventricle is
located between the lower layer of tela choroidea and
the upper surface of the pineal body. The paired parallel
strands of choroid plexus in the roof of the third
ventricle are attached to the lower layer of tela choroidea. The internal cerebral veins arise in the anterior
part of the velum interpositum, just behind the foramen
of Monro, and they exit the velum interpositum by
passing between the pineal body and splenium to enter
the quadrigeminal cistern where they join the great
vein.

Arterial Relationships. The arteries related to the

body portion of the choroidal fissure are the small
terminal branches of the medial and lateral posterior
choroidal arteries (Figure 9). The medial posterior
choroidal arteries arise in front of the midbraln from the
proximal part of the posterior cerebral artery. They
usually arise as one to three branches. They course
parallel and medial to the posterior cerebral artery
through the basal cisterns to reach the area beside the
pineal gland. They may infrequently arise in the quadrigeminal and ambient cisterns from the main trunk or
cortical branches of the posterior cerebral artery. Upon
reaching the area beside the pineal gland, they turn
forward and enter the velum interpositum where they
course on and around the much larger veins in the
velum interpositum. These small arteries supply the
choroid plexus in the roof of the third ventricle and
sometimes pass through the ipsilateral foramen of
Monro or choroidal fissure to reach the choroid plexus
in the ipsilateral lateral ventricle. They occasionally
send branches through the contralateral choroidal fissure and foramen of Monro to supply the choroid
plexus in the opposite lateral ventricle.

Surg Neurol
1988;30:3-59

31

The lateral posterior choroidal arteries arise from the

posterior cerebral artery distal to the origin of the
medial posterior choroidal arteries. They are the most
frequent arteries to pass through the body portion of
the choroidal fissure. The branches of the lateral posterior choroidal arteries reach the choroid plexus in the
body of the lateral ventricle by one of two routes: they
may either pass directly from their origin through the
atrial or temporal portions of the fissure and course
around the thalamus in the choroid plexus to reach the
body of the lateral ventricle, or they may course around
the thalamus just medial to the choroidal fissure to
reach the velum interpositum where they penetrate the
fissure to reach the choroid plexus in the body. The
lateral posterior choroidal arteries may send branches
through the contralateral choroidal fissure to the choroid plexus in the opposite lateral ventricle. The lateral
and medial posterior choroidal arteries may send tiny
branches to the neural structures along their course.

Venous Relationships. The veins related to the body

portion of the fissure are the ventricular veins arising in
the frontal horn and body of the lateral ventricle and the
internal cerebral veins which course on the medial side
of the fissure in the velum interpositum (Figures 4 and
7-9). The veins coursing in the walls of the frontal horn
and body of the lateral ventricle exit the ventricle by
passing through the body portion of the choroidal
fissure. The medial group of ventricular veins is formed
by the anterior and posterior septal veins, and the lateral
group consists of the thalamostriate, thalamocaudate,
and anterior and posterior caudate veins. The veins of
the lateral group are larger than those of the medial
group. The veins in the lateral group penetrate the tenia
choroidea to reach the velum interpositum.
The anterior septal veins course medially across the
roof and anterior wall of the frontal horn to reach the
septum pellucidum where they pass around the column
of fornix and terminate in the internal cerebral vein.
The posterior septal veins course medially across the
roof of the body of the lateral ventricle and turn
downward on the septum pellucidum. They terminate
by penetrating the junction of the fornix and septum
pellucidum to enter the velum interpositum where they
join the internal cerebral vein. The anterior caudate
veins course on the lateral wall of the frontal horn on
the surface of the head of caudate nucleus and terminate
near the foramen of Monro in the thalamostriate vein.
The posterior caudate veins originate at the lateral edge
of the body of the ventricle and course across the
caudate nucleus to terminate in the thalamostriate or
thalamocaudate veins.
The thalamostriate vein is a large vein that passes
forward in the sulcus between the caudate nucleus and

32

Figure 9. Vascular relationships of the choroidalfissure. (A) Superior view. The upper part of the cerebral hemispheres has been removed to expose the
frontal (Front. Horn) and temporal horns (Temp. Horn) and bodies of the lateral ventricles (Body Lat. Vent.). The choroidplexus (Chor. Plex.) in the right
atrium has been detached and retractedposteriorly to expose the choroidalfissure (Chor. Fiss.). The anterior (Ant. Chor. A.) and lateral posterior choroidal
arteries (Lat. Post. Chor. A.) pass through the choroidalfissure to reach the c h o r o ~
The thalamocaudate (Thal. Caud. V.) and superior choroidal
veins (Sup. Chor. V.) pass through the body portion of the right choroidalfssure. The structures exposed in the walls of the lateral ventricles include the
caudate nuclei (Caud. Nucl.), corpus callosum (Corp. Call.), septum pellucidum (Sep. Pell.), thalamus, collateral trigone (Coll. Trig.) and eminence (Coll.
Emin.),foramen of Monro (For. Monro), and the hippocampalformation ( H i p p o . ) . ~ r g e d view of the right lateral v e ~ c h o r o i d a l
fissure. T'-T-~-ee
crus and right half of the b ~ r n i x
have been removed to expose the layer of tela choroidea (Tela) that forms the roof of the velum interpositum (Vel.
lnterpos.). The site of the bodyportion of the choroidalfissure is shown by the dotted line. Other structures in the exposure include the medial atrial (Med. Atr.
V.__)an-'n-d-internalcerebral veins (Int. Cer. V.), the middle cerebralartery (M.C.A.) and the Sylvian fissure (Sylvian Fiss.).

Choroidal Fissure

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1988;3(1:3-59

33

Figure 9. (C) The tela choroid~a has been removed to expose the vessels that course in the velum interpositum. The medial posterior choroidal arteries (Med.
Post. Chor. A.) course through the quadrigeminal cistern (~uad. Cist.) to reach the velum interpositum. (D) The body and crura of the fornix anTfft-~e
splenium of the corpus callosum have been removed. The lateral posterior choroidal arteries course around the pulvinar to supply the ckoroid plexus in the body
of the lateral ventricle. The medial posterior choroidal arteries course with the internal cerebral veins. The anterior choroidal arteries ~upply the choroid plexus
in the temporal horns and atria. The basal (Basal V.), internal occipital (Int. Occip. V.), medial atrial and internal cerebral veins converge on the
quadrigeminal cisterns. The anterior septal (Ant. Sept. V.), anterior caudate (Ant. Caud. V.), thalamostriate (Thai. Str. V. ), and thalamocaudate veins
join the internal cerebral veins. The striothalamic sulcus (Str. Thal. Sulc. ) is located between the caudate nucleus and thalamus.

34

Surg Neurol
1988;30:3-59

thalamus. It turns sharply posterior at or near the

posterior margin of the foramen of Monro to enter the
velum interpositum where it joins the internal cerebral
vein. The angle formed by the junction of the thalamostriate and internal cerebral veins, called the venous
angle, as seen on the lateral view of the cerebral
angiogram, approximates the site of the foramen of
Monro. In some cases this venous angle will not approximate the site of the foramen of Monro because the
thalamostriate vein passes through the choroidal fissure
well behind the foramen of Monro.
The thalamocaudate vein courses medially across the
caudate nucleus and thalamus behind the posterior
extent of the thalamostriate vein. It passes through the
margin of the choroidal fissure well behind the foramen
of Monro to empty into the internal cerebral vein. The
size of the thalamocaudate vein is inversely proportional
to the size of the thalamostriate vein. If the thalamostriate vein is so large that it reaches the posterior
part of the body of the lateral ventricle, the thalamocaudate vein will be absent, but if the thalamostriate vein is
small or absent the thalamocaudate vein will be large.
The internal cerebral veins originate just behind the
foramen of Monro and course posteriorly within the
velum interpositum. Initially, they follow the gentle
convex upward curve of the striae medullaris thalami,
but further distally, as they course along the superolateral surface of the pineal, they follow the concave
upward curve of the lower surface of the splenium. The
union of the paired internal cerebral veins to form the
great vein may be located above or posterior to the
pineal body and below or behind the splenium.
The superior and inferior choroidal veins are the
largest veins on the choroid plexus. The superior choroidal vein, the largest of the choroidal veins, runs
forward on the choroid plexus in the body of the lateral
ventricle and terminates near the foramen of Monro in
the thalamostriate or internal cerebral veins or their
tributaries.

Temporal Part of the Choroidal Fissure

Neural Relationships. The temporal part of the choroidal fissure is situated in the medial wall of the
temporal horn between the fimbria of the fornix and the
inferolateral part of the thalamus (Figures 1, 2, 5, 6, 10,
and 11). Opening through the choroidal fissure from the
temporal horn exposes the structures in the ambient
and posterior part of the crural cisterns.
The temporal horn through which the temporal
portion of the choroidal fissure is approached extends
forward from the atrium below the pulvinar into the
medial part of the temporal lobe. The temporal horn

Nagata et al

ends blindly in an anterior wall formed by the ventricular surface of the amygdaloid nucleus. The inferior end
of the choroidal fissure, called the inferior choroidal
point, is situated between the lateral geniculate body
and tail of caudate nucleus in the area just behind the
uncus and amygdaloid nucleus. The medial part of the
floor of the temporal horn is formed by the hippocampus, the smooth prominence overlying the hippocampal
formation. The lateral part of the floor is composed of
the collateral eminence, the prominence overlying the
collateral sulcus which separates the parahippocampal
and occipitotemporal gyri. The medial part of the roof is
formed by the inferior surface of the thalamus and the
tail of the caudate nucleus. The lateral part of the roof is
formed by the fibers of the tapetum of the corpus
callosum which also sweeps downward to form the
lateral wall of the temporal horn. The tapetum separates
the temporal horn from the optic radiations. The only
structure in the medial wall is the choroidal fissure. The
choroid plexus is attached to the free edge of the fimbria
by the tenia fimbriae and to the inferolateral edge of the
thalamus by the tenia choroidea.
The temporal and also the atrial parts of the choroidal fissure are located just above the tentorial incisura. The midbrain is situated in the center of the
incisura. The space between the midbrain and tentorial
edge contains the crural, ambient, and quadrigeminal
cisterns, all of which can be reached through the
choroidal fissure from the lateral ventricle. Opening
through the temporal part of the fissure exposes the
structures in the ambient cistern.
The cisternal side of the temporal portion of the
choroidal fissure is situated in the superolateral edge of
the ambient cistern. This narrow cistern is demarcated
medially by the midbrain, above by the pulvinar, and
laterally by medial surface of the temporal lobe. That
surface of the temporal lobe in the lateral wall of the
fissure is formed by three longitudinal strips of neural
tissue, one located above the other, which are interlocked with the hippocampal formation. The most
inferior strip is formed by the rounded medial edge of
the parahippocampal gyrus called the subiculum, the
middle strip is formed by the dentate gyrus, and the
superior strip is formed by the fimbria of the fornix. The
choroidal fissure is located just above the fimbria. The
ambient cistern opens anteriorly into the crural cistern
which is situated immediately below the optic tract
between the cerebral peduncle and uncus. The crural
cistern cannot be reached through the choroidal fissure
unless the anterior wall of the temporal horn is opened
using an incision extending forward from the inferior
choroidal point through the amygdaloid nucleus and the
uncus. The crural cistern may also be opened by
removing the uncus and amygdaloid nucleus.

Choroidal Fissure

Surg Neurol
1988;30:3-59

35

Figure 10. Vascular relationships of the right choroidal fissure. (A) Lateral views. The lateral part of the right cerebral hemisphere has been removed in
order to expose the frontal (Front. Horn) and temporal horns (Temp. Horn), body (Body Lat. Vent. ), and atrium of the right lateral ventricle. The choroidal
fissure (Chor. Piss.) is hidden by the choroid plexus (Chor. Plex.). The choroidal fissure extends from the foramen of Monro (For.iMonro) to the inferior
choroida~f.
Chor. Point). Other structures in t--ih-iTxpo"~-~uresinclude the corpus callosum (Corp. Call.), septum p e l l u c i d u ~ .
), hippocampal
formation (Hippo.), and globus pallidus (Glob. Pall. ). (B) Enlarged view of the body portion of t ~
fissure. The anterior s ~ t .
Sept. V. ) and
the thalamostriate veins (Thal. Str. V.) converge on the foramen of Monro. The caudate nucleus (Caud. Nucl.) is separated from the thalamus by the
striothalamic sulcus (Str. Thal. Sulc.). The column of the fornix passes around the superior and anterior margin of the foramen ef Monro.

36

Surg Neurol
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Nagata et al

Figure 10. (C) The bodyportion of the choroidalfissure has been opened by incising the tenia fornicis. The body of the fornix has been retracted medially to
expose the internal cerebralvein (Int. Cer. V.) in the velum interpositum (Vel. Interpos.). The superior choroidal vein (Sup. Chor. V.) courses on the choroid
plexus. (D) Right lateral view. The entire choroidalfissure has been openedby removing the thalamus. The sagittal section extends through the third ventricle
(3 Vent.) and the transversesection extends through the midbrain. Opening through the atrial part of the choroidalfissure exposesthe internal cerebral, basal
(Basal V.), and great veins (V. of Galen) and posterior cerebralartery (P.C.A.) in the ambient (Ambient Cist.) and quadrigeminal cisterns (Quad. Cist.).
T ~ I
posterior c h o r o i d ~ e d .
Post. C hor. A. ) passes t h r o u ~ q u a d r i g e m i n a l c i s ~ a c - h - i - h e choroidplexus in roof of the third ventricle
(Chor. Plex. 3 Vent.). Other structures in the exposure include the massa intermedia (Massa Int.), posterior commissure (Post. Comm.), superior colliculus
(Sup. Coll.), and medial geniculate body (Med. Gen. Body).

Choroidal Fissure

Surg Neurol
1988;30:3-59

.A ~

37

38

Surg Neurol
1988;30:3-59

Nagata et al

Figure 11. Arterial relationships of the choroidal fissure. (A) Lateral views. The lateral part of the left cerebral hemisphere has been removed in order to
expose the frontal (Front. Horn) and temporal horns (Temp. Horn), body (Body Lat. Vent.), and atrium of the lateral ventricle. The choroidal fissure (Chor.
Fiss.) is hidden by the choroid plexus (Chor. Plex.). Structures exposed in the walls of the lateral ventricle include the body and bulb of the corpus ca osl~'fmum
(Corp. Call.), calcar avis, collateral t r i g ~ T r i g . )
and eminence (Coll. Emin.), septum pellucidum (Sept. Pell. ), and hippocampal formation (Hippo.).
(~L~d
view of the temporal portion o f ~ l
fissure. The c h ~ s
of the temporal horn ~'aT~e--n'eTevatod,and the choroidal fissure-h-aT"brien
opened between the fimbria of the fornix and the choroidplexus by incising the tenia fimbriae to expose the ambient cistern (Ambient Cist. ). A lateral posterior
choroidal artery (Lat. Post. Chor. A.) courses below the pulvinar through the ambient cistern.

Choroidal Fissure

Surg Neurol
1988;30:3-59

39

Figure 11. (C) The opening in the temporalportion of the choroidalfissure has been lengthened to expose the posterior cerebral ( ~ ) ,

parietooccipital
(Par. Occip. A. ) and calcarine arteries (Calc. A ), and the basal vein (Basal V. ) in the ambient cistern. The lateral posterior choroidal~rteries can be retracted
superiorly along with the choroidplexus when the tenia fimbriae is o p ~ h e
rounded medial edge of the parahippocampal gyrus (Plarahippo. Gyr.) called
the subiculum is in the lateral wall of the ambient cistern. (D) The anterior half of the body portion of the choroidalfissure has been opened by incising along
the tenia fornicis, and the fornix has been retracted to expose the layer of tda choroidea that forms the roof of the velum interpositum (Vel. Inurpos.). The
anterior septal vein (Ant, Sept. V. ) joins the internal cerebralvein (Int. Cer. V. ) in the velum interpositum. Branches of the laterM and medial posterior
choroidal arteries (Med. Post. Chor. A. ) pass through the choroidalfissure to supply the choroidplexus. Other structures in the exposure include the caudate
nucleus (Caudate Nucl. ) and the third ventricle (3 Vent.).

40

Surg Neurol
1988;30:3-59

Nagata et al

Figure 11. (E) The parts of the body and crus of the fornix and the pulvinar bordering the choroidalfissure have been removedin order to exposethe courseof
the choroidal arteries through the ambient and quadrigeminal cisterns (Quad. Cist.) and the velum interpositum. The posterior cerebral artery courses
through the ambient cistern medial to the temporalportion of the choroidalfissure. The anterior choroidal arteries (Ant. Chor. A.) enter the temporal horn
near the inferior choroidalpoint (Inf. Chor. Point). Two lateral posterior choroidalarteries and the basal vein coursethrough the ambient cistern. The medial
posterior choroidal arteries supply the choroid plexus in the roof of the third ventricle (Chor. Plex. 3 Vent. ).

A r t e r i a l Relationships. The arteries that may be exposed by opening through the temporal portion of the
choroidal fissure are the posterior cerebral and the
anterior, medial posterior, and lateral posterior choroidal arteries (Figures 3, 10, 11, and 12).
The trunks and branches of the posterior cerebral
artery course through the ambient cistern just medial to
the temporal portion of the choroidal fissure. The
posterior cerebral arteries arise in front of the midbrain
well anterior and medial to the choroidal fissure. Each
posterior cerebral artery courses laterally around the
cerebral peduncle to enter the ambient cistern. It then
passes through the ambient cistern just medial to the
temporal horn and enters the lower anterior part of the
quadrigeminal cistern. Its branches reach the walls of
the temporal horn, atrium, and body of the lateral
ventricle. Opening the choroidal fissure in the temporal
horn and atrium exposes the midportion of the posterior cerebral artery and its trunks. The medial posterior
choroidal arteries course beside the posterior cerebral
artery in the area medial to the temporal portion of the
choroidal fissure.

The thalamogeniculate branches of the posterior

cerebral artery arise in the ambient cistern near the
inferior end of the choroidal fissure and pass upward
through the geniculate bodies to reach the thalamus and
the adjacent part of the internal capsule. The thalamoperforating arteries arise in front of the brainstem
from the proximal part of the posterior cerebral arteries
and the posterior part of the posterior communicating
arteries and enter the brain far anterior to the choroidal
fissure by penetrating the posterior perforated substance.
This anterior choroidal artery arises from the internal
carotid artery and courses posteriorly between the
cerebral peduncle and uncus and below the optic tract
to reach the anterior margin of the ambient cistern. The
artery then passes through the choroidal fissure to enter
the choroid plexus by penetrating the tenia choroidea
near the inferior choroidal point. It usually supplies the
choroid plexus in the temporal horn and a portion of
that in the atrium, but it may pass along the plexus to
reach the foramen of Monro in a few cases. There are
frequent anastomoses between the branches of the

Choroidal Fissure

anterior and lateral posterior choroidal arteries on the

surface of the choroid plexus. The anterior choroidal
artery gives rise to branches that penetrate the neural
structures along its course to supply part of the globus
pallidus, genu and posterior limb of the internal capsule,
amygdaloid nucleus, hippocampus, uncus, tail of the
caudate nucleus, optic pathways, midbrain, and thalan'lus.
The lateral posterior choroidal arteries are the one to
six branches of the posterior cerebral artery or its
cortical branches that arise in the ambient and quadrigeminal cisterns and pass through the choroidal fissure
by penetrating the tenia choroidea on the thalamic side
of the fissure. Most of these arteries arise in the ambient
cistern. From their origin they pass laterally around the
pulvinar and through the choroidal fissure at the level of
the fimbria, crus, or body of the fornix to reach the
choroid plexus. They enter the ventricle behind the
branches of the anterior choroidal artery. If the anterior
choroidal artery supplies the choroid plexus in the
temporal horn and atrium, the lateral posterior cho-

Surg Neurol
1988;30:3-59

41

roidal arteries will course outside the ventricle along the

medial edge of the temporal and atrial parts of the
choroidal fissure and reach the choroid plexus by passing through the body portion of the choroidal fissure.
The lateral posterior choroidal arteries may send
branches to the choroid plexus in the third ventricle, or
through the foramen of Monro or contralateral choroidal fissure to the choroid plexus in the body of the
opposite lateral ventricle. Their branches intermingle
with the branches of the medial posterior choroidal
arteries in the body of the lateral ventricle and at the
foramen of Monro. The walls of the ambient cistern are
supplied by the perforating branches of the anterior
choroidal and posterior cerebral arteries.
Venous Relationships. The basal vein is the largest
vein related to the temporal portion of the fissure
(Figures 4, 10, and 11). It arises below the anterior
perforated substance and enters the ambient cistern
from the crural cistern. The basal vein courses superomedial to the posterior cerebral artery along the upper

Figure 12. Vascular relationships. Temporal and atrial portions of the choroidalfissure. (A) Superolateral view. All of the left cereb~lhemisphere exceptfor
the lowerpart of the temporal lobe (Temp. Lobe) has been removedto exposethe temporal horn (Temp. Horn). The part of the thalamus t~at forms the upper lip
of the choroidal fissure (Chor. F i s ~
removed, but the lower lip of the fissure f o r m e ~ b r i a
of the fornix has been ,reserved. The anterior
choroidal artery (Ant. Ch---or---r.A.-Toriginates from the carotid artery (Car. A.) and courses through the crural cistern (Crural Cist.)land enters the choroid
plexus (Chor. Plex.) by passing through the choroidalfissure. The p o s ~ r e b r a l artery (P.C.A.) coursesthrough the ambient cistern (Ambient Cist. ) and
gives r i ~ e r a l
posterior choroidal arteries (Lat. Post. Chor. A. ). The medial p o s t ~ o r o i d a l arteries (Med. Post. Chor.l A ~ n d
the
pulvinar to reach the quadrigeminal cistern (Quad. Cist. ). Other structures in the exposure include the cerebralpeduncle (Ped.), kippocampal formation
(Hippo.), collateral eminence (Coll. Emin.), anterior (Ant. Comm.), posterior (Post. Comm.), and habenular commissures (Ha-'~-.Co~m.), third ventricle (3
caudate nucleus ( C a u ~ ,
parahippocampal gyrus (Parahipp~. ~
~'ubstantia nigra (Subst. Nigra), optic (Op!ic N.) and oculomot~r
nerves (II.__I),and the posterior (Post. Comm. A.) and middle (M.C.A.) communicating and anterior cerebralarteries (A.C.A.).

42

~ .
~I~

..~.

~-

~.~

'~

~.~.~

.~

~. ~ 1 ~
~ ~ ~
~~

~.~.~
~

~ '~1~
~ ~ ~:1
~1~ ~ ~ ~1

~1~ ~

Choroidal Fissure

Surg Neurol
1988;30:3-59

43

Figure 12. (D) Enlarged view, The medial and lateral posterior choroidal arteries pass through the quadrigeminal cistern. Other structures in the exposure
include the massa intermedia (Massa Int.), superior (Sup. Coll.), and inferior colliculi (Inf. Coll.) and the striothalamic sulcus ~Str. Thal. Sulc.). (E)
Enlarged view. The medial p o s ~ i d a l
arteries course t~ough the quadrigeminal cistern and the roof of the third ventricle toward the foramen of
Monro (For. Monro).

44

Surg Neurol
1988;30:3-59

part of the cerebral peduncle and below the pulvinar to

reach the quadrigeminal cistern. It may infrequently
terminate in a sinus in the free edge of tentorium.
The veins that pass through the temporal portion of
the choroidal fissure arise in the walls of the temporal
horn and join the basal vein or its tributaries in the
ambient cistern. The medial group of veins courses in
the roof and lateral wall of the temporal horn and the
lateral group courses in the floor. The roof and lateral
wall are drained predominantly by the inferior ventricular vein and the floor is drained by the transverse
hippocampal veins. The inferior ventricular vein arises
in the posterolateral part of the roof of the temporal
horn and courses obliquely anteromedial near the tail of
the caudate nucleus. It exits the temporal horn just
behind the inferior choroidal point by passing through
the tenia choroidea to join the basal vein near the lateral
geniculate body. The transverse hippocampal veins are a
group of tiny veins that course medially across the
hippocampal formation and penetrate the attachment of
the fimbria to the hippocampus to enter the ambient
cistern where they empty into the basal vein or its
tributaries. The inferior choroidal vein courses anteriorly on the choroid plexus in the temporal horn. It
terminates by passing through the choroidal fissure near
the inferior choroidal point, and empties into the basal
vein or its tributaries. The superior and inferior choroidal veins frequently anastomose on the choroid
plexus in the atrium.
Other veins that course on the medial side of the
temporal portion of the choroidal fissure and empty into
the basal vein include the lateral mesencephalic vein
which runs vertically along the side of the midbrain and
the veins draining the cortical surface of the temporal
lobe bordering the basal cisterns.

Atrial Part of the Choroidal Fissure

Neural Relationships. The atrial part of the choroidal
fissure is situated between the crus of the fornix and the
pulvinar (Figures 1, 6, 10, 11, and 13). Opening through
the fissure from the atrium exposes the quadrigeminal
cistern, the pineal region, and the posterior portion of
the ambient cistern.
This part of the fissure is located at the junction of
the medial and anterior walls of the atrium. The choroidal fissure does not extend into the occipital horn;
however, the atrium and occipital horn are considered
together because both are exposed in approaching the
atrial portion of the choroidal fissure. Together the
atrium and occipital horn form a roughly triangular
cavity with the apex posteriorly in the occipital lobe and
the base anteriorly on the pulvinar. The atrium opens
anteriorly above the thalamus into the body of the

Nagata et al

ventricle, anteriorly below the thalamus into the temporal horn, and posteriorly into the occipital horn. The
roof of the atrium is formed by the body, splenium, and
tapetum of the corpus callosum. The tapetum sweeps
laterally and inferiorly from the posterior part of the
corpus caUosum to form the roof and lateral wall of the
atrium and temporal horn. The medial wall of the
atrium is formed by two horizontal prominences which
are located one above the other: the upper prominence,
called the bulb of the corpus callosum, overlies the large
bundle of fibers, called the forceps major, that passes
through the splenium of the corpus callosum; and the
lower prominence, called the calcar avis, overlies the
deepest part of the calcarine sulcus. The lateral wall has
an anterior part, formed by the caudate nucleus as it
wraps around the lateral margin of the pulvinar, and a
posterior part, formed by the fibers of the tapetum of
the corpus callosum as they sweep downward along the
lateral margin of the ventricle. The anterior wall has a
medial part composed of the crus of the fornix, and a
lateral part formed by the pulvinar. The floor is formed
by the collateral trigone, a triangular area that bulges
upward over the posterior end of the collateral sulcus.
The occipital horn extends posteriorly from the atrium,
and varies in size from being absent to extending far
posteriorly in the occipital lobe. It may vary in size from
side to side.
Opening through the atrial part of the choroidal
fissure exposes the quadrigeminal cistern. The choroid
fissure lies at the junction of the anterior and lateral
walls of the quadrigeminal cistern. This cistern encloses
a space that corresponds to the pineal region. The
lateral walls of the quadrigeminal cistern separate the
cistern from the atria. Each lateral wall has anterior and
posterior parts: the anterior part is formed by the crus
of the fornix and the posterior part is formed by the part
of the medial surface of the occipital lobe situated below
the splenium.
The anterior wall of the cistern has medial and lateral
parts. The medial part of the anterior wall is formed by
the quadrigeminal plate and pineal body. The supra
pineal recess of the third ventricle bulges into the
cistern above the pineal body. The lateral part of the
anterior wall of the cistern is formed by the part of the
pulvinar that lies medial to the crus of the fornix. Below
the colliculi, the cistern extends into the cleft between
the midbrain and cerebellum called the cerebellomesencephalic fissure. This fissure cannot be reached
through the choroidal fissure. The trochlear nerves arise
below the inferior colliculi and course laterally around
the midbrain and below the pulvinars to enter the
ambient cisterns.
The roof of the cistern is formed by the lower surface
of the splenium and the broad membranous envelope

Choroidal Fissure

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1988;30:3-59

45

46

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Nagata et al

Figure 13. (C) The atrium has been opened. The choroidalfissure (Chor. Fiss.) is hidden deep to the choroidal plexus (Chor. Plex.) between the fornix and
pulvinar. Other structures in the exposure include the caudate n u c l e u ~ N u d .
), corpus callosus (Corp. Call.), Septum p ~ d u m (Sept. Pell. ), lateral
and the
(Lat. Atr. V.), and medial atrial and superior choroidal veins (Sup. Chor. V.). (D) The glomus of tl~-~'o'~'~-plexus has been r e f l e c t e d ,
choroidal fissure has been opened by incising the tenia fornicis. The surface of the pulvinar is exposed medial and lateral to the choroidal fissure.

Choroidal Fissure

Surg Neurol
1988;30:3-59

47

Figure 13. (E) The opening through the atrial part of the choroidalfissure has been enlarged by an opening along the tenia fornicis, The crus of the fornix
has been retractedposteriorly in order to expose the internal cerebralvein (Int. Cer. V. ) and pineal body in the quadrigeminal cistern ~uad. Cist. ). The tela
choroidea in the roof of the third ventricle has been opened to expose the c ~ s
(Chor. Plex. 3 Vent. ), the habenular commissure ( ~ o m m . )
and
trigone (Hab. Trig.), and the posterior commissure (Post. Comm.). (F-H) Exposure of the right atrium. (F) The atrium of the right lateral ventricle has been
exposed t ~
incision in the right superior temporal and supramarginal gyri. The atrial part of the choroidalfissure is hidden deep to the glomus of the
choroidal plexus. The bulb of the corpus callosum and calcar avis are in the medial wall of the atrium.

48

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Nagata et al

Choroidal Fissure

that surrounds the great vein and its tributaries. This

broad envelope of arachnoid tissue is applied to the
lower surface of the splenium and is continuous anteriorly with the velum interpositum. It is within this
envelope, in the superomedial part of the cistern, that
the venous structures are found in the greatest density.
The superomedial location of the major veins in the
cistern contrasts with the location of the large arteries
which are found in the inferolateral part of the cistern.
The quadrigeminal cistern opens anteriorly below
the pulvinars into the ambient cisterns. The quadrigeminal cistern may communicate with the velum interpositum. Another potential cavity that may communicate with the quadrigeminal cistern is the cavum
vergae, which is located immediately above the velum
interpositum between the hippocampal commissure and
the splenium. The cavum vergae is infrequently present
because the hippocampal commissure commonly fuses
to the lower surface of the splenium.

Arterial Relationships. The trunks and branches of

the posterior cerebral artery are closely related to the
atrial part of the fissure (Figures 3 and 10-13). The
posterior cerebral artery enters the quadrigeminal cistern anteriorly, and courses through the inferolateral
part of the cistern. It commonly bifurcates into the
calcarine and parietooccipital arteries within the cistern.
The medial posterior choroidal arteries enter the quadrigeminal cistern from the ambient cistern, and course
from lateral to medial above the basal vein and below
the internal cerebral vein to reach the area beside the
pineal body where they turn forward to enter the velum
interpositum. A few medial posterior choroidal arteries
may arise from the posterior cerebral artery or its
cortical branches in the ambient or quadrigeminal cistern. The lateral posterior choroidal arteries that arise in
the quadrigeminal cistern pass laterally around the
pulvinar and through the choroidal fissure to supply the
choroid plexus in the atrium and body of the ventricle,
giving off branches to the thalamus along the way.
The superior cerebellar artery courses through the
lower part of the quadrigeminal cistern but cannot be
reached by the operative approaches directed through
the choroidal fissure. The perforating branches of the
posterior cerebral and superior cerebellar arteries supply the walls of the cistern. The posterior cerebral
arteries supply the structures above the level of the
sulcus between the superior and inferior colliculi and
the superior cerebellar arteries supply the structures
below this level.
Venous Relationships. The venous relationships in the
area medial to the atrial part of the choroidal fissure are
among the most complex in the cranium, because the

Surg Neuro!
1988;30:3-59

49

internal cerebral, basal, and great veins, and multiples of

their tributaries, converge on this area (Figures 4, 10,
11, and 13). The internal cerebral veins exit the velum
interpositum, and the basal veins exit the ambient
cisterns to reach the quadrigeminal cistern where they
join the vein of Galen. The veins from the atria
terminate in the large veins in the quadrigeminal cistern
or the velum interpositum.
The group of veins that pass through the atrial
portion of the choroidal fissure arise in the atrium and
occipital horn. The medial group consists of the medial
atrial veins, and the lateral group is composed of the
lateral atrial veins. The medial atrial veins course forward on the calcar avis and bulb of the corpus callosum
and pass through the margin of the choroidal fissure and
terminate within the velum interpositum or quadrigeminal cistern by joining either the internal cerebral,
basal, or great vein. The lateral atria~ veins drain the
anterior and lateral walls of the atrium and occipital
horn. These veins course forward on the lateral wall and
turn medially to cross the pulvinar. They pass through
the choroidal fissure to reach the quadrigeminal cistern where they join the internal cerebral, basal, or
great vein. The medial and lateral atrial veins may join
near the choroidal fissure to form a common trunk
called the common atrial vein. Other veins that converge on the supratentorial part of the cistern and
empty into the great, basal, or internal cerebral veins
include the posterior pericallosal veins, which course
around the splenium to reach the cistern, and the
internal occipital veins, which originate on or near the
calcarine and parietooccipital sulci and course anteriorly
to reach the cistern.

Discussion
Microoperative techniques are utilized during approaches directed through the choroidal fssure in order
to minimize retraction of the structures bordering the
fissure and to optimize the use of the limited exposure.
In opening the choroidal fissure, it is better to open
through the tenia fornicis and tenia fimbriae than
through the tenia choroidea, because fewer arteries and
veins pass through the tenia fimbriae and fornicis than
through the tenia choroidea. The brar~ches of the medial
and lateral posterior and anterior choroidal arteries
enter the ventricle, and the thalamos~riate, thalamocaudate, lateral atrial, and inferior ventricular veins exit the
ventricle by passing through the tenia choroidea. None
of the choroidal arteries or the major ventricular veins
pass through the tenia fornicis or the ~enia fimbriae. The
medial group of ventricular veins v~hich includes the
anterior and posterior septal, medial atrial, and transverse hippocampal veins pass through the forniceal side

50

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1988;30:3-59

Nagata et al

of the fissure, but they are smaller than the veins in the
lateral group and they often pass through the fornix
rather than directly through the tenia.
The body portion of the choroidal fissure is usually
exposed through a transcortical incision in the middle
frontal gyrus, or an anterior transcallosal incision directed through the genu and body of the corpus callosum [22,23,26,28]. The transcallosal approach is easier
to perform than the transcortical approach if the ventricles are of a normal size or are minimally enlarged.
After the ventricle is opened by either the transcortical
or transcallosal approach, the foramen of Monro is
found by following the thalamostriate vein and the

choroid plexus anteriorly to where they converge on the

foramen (Figures 14 and 15). The opening into the
lateral ventricle may expose the frontal horn and body
on the same or opposite side of the cranial exposure,
but the anatomy makes this obvious. A simple rule for
determining whether the left or right lateral ventricle
has been exposed is to determine whether the thalamostriate vein is to the left or right side of the choroid
plexus: the left lateral ventricle has been opened if the
thalamostriate vein is further to the patient's left side
than the choroid plexus, and the right lateral ventricle
has been entered if the thalamostriate vein is further to
the patient's right side than the choroid plexus. Opening

Figure 14. Comparison of left and right transchoroidal and transforniceal routes to the third ventricle. (A) The superior part of the cerebralhemispheres
has been removedto expose the frontal horns (Front. Horn), bodies (Body Lat. Vent.), and atria of the lateral ventricles. The choroidplexus (C hor. Plex.) is
attached along the choroidalfissures (Chor. Fiss.). The structuresforming the walls of the lateral ventricle include the corpus callosum (Corp. ~ i x ,
V. ),
thalamus, septum pellucidum (Sept. P ~ h e
caudate nucleus (Caudate Nucl. ). The anterior septal (Ant. Sept. V. ), anterior c a u ~ a u d .
and superior choroidal veins ( S ~
V. ) join the thalamostriate veins (Thal. Str. V. ) near the foramen of Monro (For. Monro). A thalamocaudate vein
(Thal. Caud. V.) crossesthe walls of the left lateral ventricle.

Choroidal Fissure

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1988;30:3-59

51

52

Surg Neurol
1988;30:3-59

Nagata et al

Choroidal Fissure

Surg Neurol

1988;30:3-59

~-~1
~ ~.~

~~.~
~.~. ~..~
~

.~

~.~

53

54

Surg Neurol
1988;30:3-59

Nagata et al

Figure 15. Transchoroidal approach directed through the bodyportion of the choroidalfissure using an opening through the corpus callosum. The site of the
scalp inciston and boneflap are shown in the inset on the upper left. (A) Operative exposure of the frontal horn (Front. Horn) and body of the right lateral
ventricle (Body Lat. Vent.). The choroidalfissure (Chor. Fiss.) lies deep to the choroid plexus (Chor. Plex.). Structures in the wqll of the lateral ventricle
include the thalamus, caudate nucleus (Caudate N ~ x ,
foramen of Monro (For. Monr~,-~pt-ffm-pellucidum (Sept. PeU.), and the rostrum of the
corpus callosum (Corp. Call.). Vascular structures that converge on the choroidalfissure include the medial (Med. P o ~ A . )
and lateral posterior
choroidal a r t e r i e s ~ C h o r .
A.) and the anterior (Ant. Sept. V.) and posteriorseptal (Post. Sept. V.), anterior (Ant. Caud. V.) and posterior caudate
(Post. Caud. V.), superior choreidal (Sup. Chor. V.), and thalamostriate veins (Thai. Str. ~ h o r o i d a l
fissure has been opened by incising along
the tenia fornicis. The layers of tela choroidea in the roof of the third ventricle have been openedand the massa intermedia (Massa Int. ) and interior and floor
of the third ventricle (3 Vent. ) have been exposedby separating the internal cerebralveins (Int. Cer. V. ). The medial p o s t e r ~ l
arteries coursearound
the internal cerebralveins.

the septum pellucidum will provide access to the opposite lateral ventricle and to the opening of the foramen
of Monro into both lateral ventricles. Entry into a
cavum between the leaves of the septum peUucidum

may be confusing until one realizes that no intraventricular structures are present.
Routes through the lateral ventricles to the anterior
part of the third ventricle, other than those directed

Choroidal Fissure

through the intact foramen of Monro or by enlarging

the foramen of Monro by incising the ipsilateral column
of the fornix, are by the transchoroidal approach, in
which the body portion of the choroidal fissure, is
opened, thus allowing the fornix to be pushed to the
opposite side, or the transforniceal approach, in which
the body of the fornix is split in the midline in the
direction of its fibers (Figures 14 and 15). The transchoroidal and transforniceal approaches have the advantage
of giving access to the portion of the third ventricle
behind the foramen of Monro by displacing, rather than
transecting, the fibers in the fornix.
When the approach through the corpus caUosum is
used, the transforniceal and transchoroidal routes provide a satisfactory view into the third ventricle. When
the approach through the middle frontal gyrus is used
the transchoroidal approach provides a better view into
the third ventricle than the transforniceal route. It is
easier to direct the approach through the tenia fornicis
than through the tenia choroidea when the third ventricle is exposed through the corpus callosum. The transchoroidal approach is especially well suited to lesions
that are fed by the terminal branches of the choroidal
arteries. In the transchoroidal approach, the third ventricle is exposed by opening the choroidal fissure along
the tenia fornices and displacing the fornix to the
opposite side, after which the roof of the third ventricle
is entered by opening the layers of tela choroidea.
Opening through the velum interpositum in the interval
between the internal cerebral veins allows a more
extensive exposure of the third ventricle than if the
third ventricle is exposed between the ipsilateral internal cerebral vein and the thalamus. It is often necessary
to sacrifice some of the branches of the internal cerebral
vein if the third ventricle is entered on the lateral side of
the internal cerebral vein; however, the roof of the third
ventricle can commonly be entered without sacrificing
any branches of the internal cerebral veins if the
approach is directed between these veins. Tiny branches
of the medial and lateral posterior choroidal arteries
may cross the midline in the velum interpositum, but
the risk of sacrificing these fine arterial branches are
minimal. After opening the lower layer of tela choroidea, the choroid plexus in the roof of the third
ventricle, the sulcus limitans, massa intermedia, and
floor of the third ventricle are encountered (Table 2).
In prior reports the choroidal fissure was opened by
incising the tenia choroidea, but this approach risks
damage to the thalamus and the vessels that pass
through the thalamic side of the fissure by penetrating
the tenia choroidea. Hirsch et al [13], Delandsheer et al
[5], and Lavyne et al [15] have reported cases in which
the thalamostriate vein was interrupted during the
subchoroidal approach without ill effect; however, oc-

Surg Neurol
1988;30:3-59

55

clusion of the thalamostriate vein and its tributaries at

the foramen of Monro may cause hemorrhagic infarction of the basal ganglia [13,15,24].
The fact that the genu of the internal capsule touches
the wall of the ventricle in the area lateral to the
foramen of Monro near the anterior pole of the thalamus should be kept in mind when retraCting the walls of
the lateral ventricle. Care should be exercised in retracting this area because a thin brain spatula could
easily cut into the ventricular wall and the genu of the
internal capsule in this area.
The quadrigeminal cistern, pineal region and the
posterior part of the ambient cistern can be exposed
through the atrial part of the choroidal fissure (Figure
16). The transchoroidal approach to the quadrigeminal
cistern is most commonly used for arteriovenous malformations or vascular tumors that are located behind
the pulvinar in the region of the choroidal fissure. Pineal
tumors have been removed by a transventricular approach directed through the medial wall of the lateral
ventricle, however, the narrowness and heavy vascularization of the pineal area make it difficult to approach
pineal tumors by this route [28,29,32]. The occipital
transtentorial approach and the infratentorial supracerebellar approaches are most commonly used for exposing tumors in the pineal region [20-23].
The atrial part of the choroidal fissure has been
approached through cortical incisions in the superior
parietal lobule, the superior and middle temporal gyri,
and the temporoparietal junction. The preferred approach is through the superior parietal ilobule. Opening
the atrium through the temporopariet~ area may cause
a homonymous visual field deficit due to the interruption of the optic radiations in either hemisphere, disturbances of visuospacial function in the nondominant
hemisphere, and aphasia and agnostic disorders in the
dominant hemisphere [3,25]. Opening through the
middle temporal gyrus might be considered for a lesion
in the dominant hemisphere, but Cortical mapping
during surgery has revealed an occasional extension of
the speech representative into the middle temporal
gyrus [18].
After entering the atrium, the glomus of the choroid
plexus is retracted laterally to expose the tenia fornicis
which is opened with a fine knife. Care is taken to avoid
damaging the lateral posterior choroidal arteries that
course just medial to the choroidal fissure and through
the tenia fornicis. Retracting the crus medially and
posteriorly opens the quadrigeminal cistern and the
caudal portion of the ambient cistern. The retraction
should be carefully applied because the retractor may
damage the calcar avis and the underlying visual cortex
in the medial wall of the atrium. Retraction of the
pulvinar should be minimized in order to prevent

56

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Nagata et al

Figure 16. Transchoroidal approach directed through the atrial portion of the choroidalfissure using a cortical incision in the superiorparietal lobule. The
site of the scalp incision, boneflap, and cortical incision are shown in the inset on the upper left. (A) The choroidplexus (Chor. Plex.) is attached along the
choroidalfissure (Chor. Fiss.). The atrial portion of the choroidalfissure is situated between the crus of the fornix and the p ~
Structures in the wall of
the atrium, body ~
Lat. Vent.), and temporal horn (Temp. Horn) of the lateral ventricle include the pulvinar, fornix, caudate nucleus (Caudate Nucl. ),
tapetum and bulb of the corpus callosum (Corp. Call.), calcaravis, hippocampalformation (Hippo.) and collateral eminence (Coll. Emin.) and trigone (Coll.
Trig.). Vascular structures that converge~ i d a l fissure include the anterior (Ant. ~ .
) and lateral posterior c h o ~ i e s
(Lat. Post. C-h-~or.
__i)"and the lateral (Lat. Atr. V. ) and medial atrial (Med. Atr. V. ), posterior caudate (Post. Caud. V. ), superior (Sup. C hor. V. ) and inferior choroidal (Inf.
Chor. V. ), and transverse hippocampal veins (Trans. Hippo. V. ). (B) The choroidalfissure has beenopenedby incising along the tenia fornicis and retracting
the crus of the fornix posteriorly to expose the quadrigeminal cistern (Quad. C ist. ), posterior cerebral(P.C.A. ), and medial posterior choroidal arteries, pineal
body and internal cerebral (Int. Cer. V. ), basal (Basal V. ) and great veins (V. of Galen).

language and speech disturbances because the pulvinar

is the main site of origin of thalamic fibers to the
association cortex at the junction of the parietal, temporal and occipital lobes that are involved in speech and

vision [3]. If the pulvinar bulges too far posteriorly, a

supplemental horizontal incision in the medial wall of
the atrium behind the crus may be needed in order to
avoid retraction of the pulvinar; however, extending

Choroidal Fissure

this incision posteriorly into the calcar avis will cause a

visual field deficit. The opening into the quadrigeminal
cisterns may be obtained by making an arcuate incision
along the direction of the fibers in the crus of the fornix
instead of using the approach through the choroidal
fissure.

Surg Neurol
1988;30:3-59

57

The approach through the temporal part of the

choroidal fissure is used for lesions in the medial part of
the temporal lobe and in the ambient cistern (Figure
17). The main advantage of this approach is that the
posterior cerebral and the anterior and posterior choroidal arteries, and the basal vein can be exposed

Figure 17. Transchoroidal approach directed through the temporal portion of the choroidal fissure. The inset on the upper left shows the site of the scalp
incision and boneflap. (A) The inferior surface of the temporal lobe (Temp. Lobe) has been opened to expose the temporal horn (Ter~p. Horn). The choroid
plexus (Chor. Plex.) is attached along the choroidal fissure (Chor. F ~ u r e s
in the wall of the temporal horn include the bippocampal formation
(Hippo~
eminence (Coll. Emin.), amygdaloid (Amygd. Nucl.) and caudate nuclei (Caudate Nud.), and the tapetum pf the corpus callosum.
~Tcu"lar structures that pass ~ c h o r o i d a l
fissure (Chor. Fiss.) include the anterior (Ant. Chor. A. ) and lateral posterior ~horoidal arteries (Lat.
Post. Chor. A. ) and the transverse hippocampal (Trans. Hippo. VI ), amygdalar (Amygd. V. ), inferior choroidal (Inf. Chor. V. ), and inferior ventric*-~-r
veins (Inf. Vent. V.). (B) The choroidal fissure has been opened by incising along t ~ m b r i a e
and retracting the choroid plexu~ upward. This exposes
the ambient cistern (Ambient Cist.), branches of the posterior cerebralartery (P.C.A.), and tributaries of the basal vein (Basal V.). The medial posterior
choroidal artery (Med. Post. Chor. A. ) courses medial to the posterior cerebral

58

Surg Neurol
1988;30:3-59

without extensive retraction of the temporal lobe. The

approach is especially useful for exposing arteriovenous
malformations of the temporal horn, hippocampus, and
medial part of the temporal lobe that are fed by the
arteries entering and drained by the veins exiting the
choroidal fissure [6,27,30].
The temporal portion of the choroidal fissure is
usually exposed through a cortical incision on the lateral
or inferior surface of the temporal horn. The transchoroidal approach to the basal cisterns reduces the risks of
injury to the vein of Labb6 and the swelling and
hematoma of the temporal lobe that may result from the
extensive retraction required to reach the ambient
cistern by the subtemporal extracerebral approach [12].
The temporal horn may be exposed using a cortical
incision in the middle temporal gyrus anterior to the
optic radiations in the nondominant hemisphere and the
inferior temporal gyrus in the dominant hemisphere.
An alternative, and often preferable route, that minimizes the possibility of damage to the optic radiations in
both hemispheres and the speech centers of the dominant hemisphere is the subtemporal route, in which an
incision is made in the inferior temporal or occipitotemporal gyrus on the inferior surface of the
temporal lobe. Heros has used the subtemporal transchoroidal approach for medial temporal arteriovenous
malformations [12]. Oliveira has recommended approaching the temporal horn through an incision along
the collateral sulcus (personal communication). The risk
of hemorrhage, venous infarction, and edema after
retraction of the temporal lobe during this approach is
reduced by avoiding occlusion of the bridging veins,
especially the vein of Labb6. The opening into the
temporal horn will expose the choroidal fissure and the
branches of the anterior and lateral posterior choroidal
arteries as they enter the choroid plexus. The inferior
ventricular vein will be seen coursing in the roof and the
tiny transverse hippocampal veins may be seen crossing
the floor of the temporal horn. The choroid plexus is
retracted upward and the choroidal fissure is opened by
incising along tenia fimbriae thus avoiding damage to
the vessels that pass through the tenia choroidea. Opening the choroidal fissure between the tenia fimbriae and
the choroid plexus permits the arteries and veins that
pass through the tenia choroidea to be retracted upward
with the choroid plexus. The transverse hippocampal
veins that pass through the forniceal side of the fissure
are not a barrier because they exit the temporal horn by
penetrating the fimbria rather than passing through the
tenia fimbriae. Opening the fissure will expose the
posterior cerebral artery, and some of its choroidal,
cortical, and perforating branches, and the basal vein
and some of its ventricular and cortical tributaries.
A posterior frontotemporal approach might be considered for a lesion involving the anterior end of the

Nagata et al

temporal portion of the choroidal fissure that could be

exposed through a temporal lobectomy or a small
cortical incision in the anterior part of the temporal
lobe. The amygdaloid nucleus lies directly anterior and
slightly above the tip of the temporal horn and is
directly lateral to the cisternal surface of the uncus.
Opening through the amygdaloid nucleus and uncus will
expose the structures in the crural cistern. This approach will expose the crural cistern and the temporal
horn as far back as the site where the anterior choroidal
artery passes through the choroidal fissure but is sufficiently anterior that it does not permit more than
minimal opening of the choroidal fissure to expose the
ambient cistern.
Opening the choroidal fissure carries the risk of
damaging the fornix. However, unilateral damage to the
fornix produces no deficit [14,19] and damage to the
forniceal fibers from both hemispheres does not usually
produce a memory loss [14,31]. This is evidence that
lesions in the crus and hippocampal commissure have a
more deleterious effect on memory than lesions in the
body or columns. In opening the body portion of the
choroidal fissure there is the risk of damage to the
dorsomedial nucleus of the thalamus. This nucleus has
afferent fibers steming mainly from the amygdaloid
complex and the temporal neocortex, and efferent
fibers directed to the prefrontal cortex. Lesions in the
dorsomedial nucleus produce emotional changes similar
to those resulting from ablations of the orbitofrontal
cortex [4]. The transforniceal approach to a lesion of
the third ventricle carries the potential risk for bilateral
damage to the fornix, but the memory deficit using this
approach is usually transient [1,2]. Opening the temporal part of the choroidal fissure risks damaging the
fimbria and hippocampal formation. There is abundant
experimental and clinical evidence that massive bilateral
damage of the hippocampal formation causes impairment of recent memory [10,11,14,19,24]. However,
unilateral damage of the hippocampal formation produces no deficit [7,9,20]. The stria terminalis which
borders the temporal portion of the choroidal fissure is
the most prominent efferent pathway from the amygdaloid nuclear complex to the nuclei of the stria terminalis. However, there is no evidence that unilateral
lesions of the stria terminalis or amygdaloid nucleus
cause emotional disturbances. Bilateral lesions of the
amygdaloid complex may produce a reduction in emotional excitability [17].

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