The prepontine cistern is the subarachnoid space anterior to the pons and posterior to the clivus, containing the basilar artery running vertically in the midline, the abducens nerves (CN VI) as they exit the pontomedullary junction and cross the cistern to enter Dorello's canal, and the anterior inferior cerebellar arteries (AICA). It communicates with the interpeduncular cistern superiorly and the cerebellomedullary (cisterna magna) cistern inferiorly.
The prepontine cistern is the endoscopic view obtained through the working channel during endoscopic endonasal clival approaches, where the clivus is drilled to expose the prepontine cistern contents for clival chordoma and petroclival meningioma resection. The basilar artery and its branches within the cistern are the primary vascular hazards. CN VI crossing this cistern explains its vulnerability to raised ICP (false localizing sign) as the nerve is stretched over the petrous apex at the cistern's lateral wall (Dorello's canal). CPA tumours (acoustic neuromas) displace the cistern's lateral contents.
Endoscopic endonasal clival drilling for chordoma or petroclival meningioma exposes the prepontine cistern where the basilar artery lies directly; inadvertent arterial injury in this cistern is catastrophic; neuronavigation, intraoperative Doppler, and staged drilling to the posterior cortex followed by careful dura opening with CSF drainage prevents uncontrolled prepontine cistern entry.
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