Microsurgical anatomy of the middle cerebral artery

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✓ The microsurgical anatomy of the middle cerebral artery (MCA) was defined in 50 cerebral hemispheres. The MCA was divided into four segments: the M1 (sphenoidal) segment coursed posterior and parallel to the sphenoid ridge; the M2 (insular) segment lay on the insula; the M3 (opercular) segment coursed over the frontoparietal and temporal opercula; and the M4 (cortical) segment spread over the cortical surface. The Sylvian fissure was divided into a sphenoidal and an operculoinsular compartment. The M1 segment coursed in the sphenoidal compartment, and the M2 and M3 segments coursed in the operculoinsular compartment. The main trunk of the MCA divided in one of three ways: bifurcation (78% of hemispheres), trifurcation (12%), or division into multiple trunks (10%). The MCA's that bifurcated were divided into three groups: equal bifurcation (18%), inferior trunk dominant (32%), or superior trunk dominant (28%). The MCA territory was divided into 12 areas: orbitofrontal, prefrontal, precentral, central, anterior parietal, posterior parietal, angular, temporo-occipital, posterior temporal, middle temporal, anterior temporal, and temporopolar. The smallest cortical arteries arose at the anterior end and the largest one at the posterior end of the Sylvian fissure. The largest cortical arteries supplied the temporo-occipital and angular areas. The relationship of each of the cortical arteries to a number of external landmarks was reviewed in detail.

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Address reprint requests to: Albert L. Rhoton, Jr., M.D., Department of Neurosurgery, Box J-265, University of Florida Health Center, Gainesville, Florida 32610.

© AANS, except where prohibited by US copyright law.

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    Relationship of the middle cerebral artery to the sphenoid ridge, Sylvian fissure, and temporal lobe. Upper: Anterosuperior view with frontal lobes removed to show the relationships of the M1 segment to the temporal lobe (Temp.Lobe) and sphenoid ridge, the M2 segment to the insula, and the M3 segment to the transverse temporal gyri (Trans.Temp.Gyr.). The lateral ventricles (Lat.Vent.) and the anterior cerebral (A.C.A.) and recurrent arteries (Rec.A.) are above the carotid arteries (C.A.) and optic (O.N.) and olfactory (I) nerves. The lenticulostriate arteries (Len.Str.A.) arise from the M1 segment and enter the anterior perforated substance (Ant.Perf.Subst.). The limen insulae is at the junction of the insula and the anterior perforated substance. The M1 segment courses in the sphenoidal compartment (Sph.Comp.) of the Sylvian fissure, and the M2 and M3 segments course in the operculoinsular compartment (Operc. Ins. Comp.). Lower: Inferior view with the poles of the temporal lobes removed to expose the M1 and M2 segments of the middle cerebral arteries. The olfactory sulcus (Olf.Sul.) separates the gyrus rectus (Gyr.rectus) and the orbital gyri (Orb.Gyr.). The lenticulostriate arteries arise from the posterosuperior side of the M1 segment and enter the anterior perforated substance. The basilar artery (B.A.) is in front of the pons and gives rise to the superior cerebellar (S.C.A.) and the posterior cerebral (P.C.A.) arteries. The posterior communicating arteries (P.Co.A.) and the oculomotor nerves (III) are seen lateral to the pituitary stalk (Stalk).

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    Anterosuperior views of the right middle cerebral artery. Upper: The right frontal lobe has been removed to show the relationship of the M1, M2, M3, and M4 segments to the temporal lobe (Temp.Lobe) and the insula. The M1 segment crosses the upper surface of the anterior pole of the temporal lobe and divides into a superior (Sup.Tr.) and inferior (Inf.Tr) trunk. The M2 segment lies on the insula, the M3 segment crosses the transverse temporal gyri (Trans.Temp.Gyr.), and the M4 segment passes inferiorly across the superior (Sup.Temp.Gyr.) and middle temporal gyri (Mid.Temp.Gyr.). The anterior cerebral artery (A.C.A.) arises from the carotid artery (C.A.) and passes above the optic nerve (O.N.) and chiasm (O.Ch.) where it gives rise to the recurrent artery (Rec.A.). The lenticulostriate arteries (Len.Str.A.) enter the anterior perforated substance (Ant.Perf.Subst.). An early branch (Early Br.) to the temporal lobe arises from the M1 segment. The frontal horns of the lateral ventricles (Lat.Vent.) lie above the anterior cerebral arteries. Lower: The relationship of the middle cerebral artery to the sphenoid ridges and temporal lobes. The M1 segments course posterior to the sphenoid ridges. The olfactory nerves (I) are seen above the optic nerves. The inferior limb (Inf.Limb) of the insular cleft lies between the temporal operculum and the insula.

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    Inferolateral views of the left cerebral hemisphere. Upper: Inferolateral view with the pole and operculum of the temporal lobe (Temp.Lobe) removed. The main trunk (Main Tr.) of the middle cerebral artery gives rise to an early branch (Early Br.) and bifurcates to give rise to a small superior trunk (Sup.Tr.) and a dominant inferior trunk (Inf.Tr.). The branches pass around the frontal (Fr.Operc.) and parietal (Par.Operc.) opercula to reach the surface of the frontal (Fr.Lobe) and parietal (Par.Lobe) lobes. The lenticulostriate arteries (Len.Str.A.) enter the anterior perforated substance (Ant.Perf.Subst.). The carotid arteries (C.A.) are seen below the olfactory nerves (I) and lateral to the optic nerves (O.N.). Lower: Inferior view. The M1 segment gives rise to the lenticulostriate arteries, which enter the anterior perforated substance. The branches forming the M2 segment enter and the M3 branches exit the superior limb (Sup.Limb) of the insular cleft. The posterior cerebral (P.C.A.), posterior communicating (P.Co.A.), and basilar (B.A.) arteries are medial to the temporal lobe.

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    Relationship of the M1 (blue), M2 (green), M3 (yellow), and M4 (red) segments of the middle cerebral arteries to the insula and Sylvian fissure. Upper Left and Right: Superolateral view of the right cerebral hemisphere with the anterior half of the frontal lobe and part of the frontoparietal and temporal opercula removed. Upper Left: The removal exposes the anterior one-fourth of the insula. Upper Right: The removal exposes the whole surface of the insula. The Sylvian fissure is divided into a sphenoidal compartment which is located posterior to the sphenoid ridge and in which the M1 segment courses. The M2 and M3 segments course in the operculoinsular compartments of the Sylvian fissure. The operculoinsular compartment is divided into an insular and an opercular cleft. The opercular cleft is located between the frontoparietal and the temporal opercula. The insular cleft is located between the insula and the opercula. The insular cleft is divided into a superior limb (Sup.Limb) located medial to the frontoparietal operculum and an inferior limb (Inf.Limb) located medial to the temporal operculum. The circular sulcus is located at the periphery of the insula. The short gyri (Short Gyr.) of the insula are located above the central sulcus of the insula and the long gyri (Long Gyr.) are located below. The carotid arteries (C.A.) and anterior perforated substance (Ant.Perf.Subst.) are at the medial end of the Sylvian fissure. The lateral ventricles (Lat.Vent.) are above the optic nerves (O.N.). A through D are anterior views of coronal sections of the right cerebral hemisphere. The central diagram shows the level of the sections. A: Coronal section at the level of the M1 segment. The M1 segment courses in the sphenoidal compartment; the M2 segment courses on the insulae; the M3 segment passes over the deep surface of the opercula, and the M4 segment courses on the cortical surface. At this anterior level, the frontal operculum covers more of the insula than the temporal operculum. B: Coronal section at the midportion of the Sylvian fissure where the frontal and temporal opercula are of nearly equal height. C: Coronal section at a more posterior level where the temporal operculum covers more of the insula than does the frontoparietal operculum. D: Coronal section from the posterior end of the Sylvian fissure. Only the opercular cleft remains; the insular cleft has disappeared.

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    Anterolateral and lateral views of the insula. Upper Left: Anterolateral view with the frontal (Fr.Operc.) and temporal (Temp.Operc.) opercula retracted to show the insula and the M1, M2, M3, and M4 segments of the middle cerebral artery (MCA). The MCA arises from the carotid artery (C.A.) lateral to the optic nerve (O.N.). The junction of the M1 and M2 segments is at the limen insulae. The M1 segment courses below the anterior perforated substance (Ant.Perf.Subst.). The superior (Sup.Tr.) and inferior (Inf.Tr.) trunks arise near the limen insulae. The pituitary stalk (Stalk) is below the optic chiasm. Upper Right: Lateral view of the right insula with part of the frontal and temporal opercula removed to show the arteries forming the M2 segment coursing over the insula. The limen insulae is located at the anteroinferior margin of the insula. The circular sulcus forms the peripheral margin of the insula, and the central sulcus of the insula separates the long insular gyri (Long Gyr.) from the short insular gyri (Short Gyr.). The lateral ventricle (Lat.Vent.) is located above the anterior cerebral arteries (A.C.A.). Lower Left: Enlarged view of the right insula with part of the frontal, parietal (Par.Operc.), and temporal opercula removed. Lower Right: Lateral view with the frontal, parietal, and temporal opercula removed to show the insula and the M2 segment. The dark line shows the location of the posterior ramus (Post.Ramus) of the Sylvian fissure. The central sulcus (Cent.Sulcus) separates the frontal from the parietal lobes. The short gyri of the insula are anterosuperior to the central sulcus of the insula, and the long gyri are posteroinferior.

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    Lateral view of the left cerebral hemisphere showing the major gyri and sulci in the area supplied by the middle cerebral artery. The central sulcus (Cent.Sul.) separates the precentral gyrus (Pre.Cent.Gyr.) from the postcentral gyrus (Post.Cent.Gyr.). The precentral gyrus, a vertically oriented gyrus, forms the posterior part of the frontal lobe, and lies between the central and precentral sulci (Pre.Cent.Sul.). The larger anterior portion of the frontal lobe is formed by the three horizontal convolutions: the superior (Sup.Fr.Gyr.), middle (Mid.Fr.Gyr.), and inferior (Inf.Fr.Gyr.) frontal gyri. The superior frontal sulcus (Sup.Fr.Sul.) separated the superior and middle frontal gyri, and the inferior frontal sulcus (Inf.Fr.Sul.) separated the middle and inferior frontal gyri. The Sylvian fissure (Sylv.Fiss.) has a stem that runs medially between the frontal and temporal lobes and three rami: the posterior ramus (Post.Ramus) separates the frontal and parietal lobes above from the temporal lobe below, the anterior horizontal ramus (Ant.Hor.Ramus) separates the pars orbitalis (Pars Orb.) from the pars triangularis (Pars Tri.), and the anterior ascending ramus (Ant.Asc.Ramus) separates the pars triangularis from the pars opercularis (Pars Operc.). The lateral surface of the temporal lobe is composed of three gyri and two sulci, all oriented in the direction of the posterior ramus of the Sylvian fissure. The superior temporal (Sup.Temp.Gyr.) and middle temporal (Mid.Temp.Gyr.) gyri are separated by the superior temporal sulcus (Sup.Temp.Sul.), and the middle and inferior temporal gyri (Inf.Temp.Gyr.) are separated by the inferior temporal sulcus (Inf.Temp.Sulc.). The inferior temporal gyrus overlaps onto the inferior surface of the hemisphere. The lateral surface of the parietal lobe has an anterior part formed by the vertically oriented postcentral gyrus that lies between the central and postcentral sulci (Post.Cent.Sul.). The larger posterior part of the lobe is formed by the obliquely oriented superior (Sup.Par.Lobule) and inferior parietal lobules (Inf.Par.Lobule) that are separated by the interparietal sulcus (Int.Par.Sul.). The inferior parietal lobule has three parts: the anterior part is formed by the supramarginal gyrus (Supramarg.Gyr.) which surrounds the posterior ramus of the Sylvian fissure, the middle part is formed by the angular gyrus (Ang.Gyr.) located at the posterior end of the superior temporal gyrus, and the posterior part extends backward to the occipital lobe. The lateral surface of the occipital lobe is divided by the lateral occipital sulcus (Lat.Occ.Sul.) into superior (Sup.Occ.Gyr.) and inferior occipital gyri (Inf.Occ.Gyr.). The cortical arteries are the orbitofrontal (Orb.Fr.A.), prefrontal (Pre.Fr.A.), precentral (Pre.Cent.A.), central (Cent.A.), anterior parietal (Ant.Par.A.), posterior parietal (Post.Par.A.), angular (Ang.A.), temporo-occipital (Temp.Occ.A.), temporopolar (Temp.Pol.A.), and the anterior temporal (Ant. Temp.A.), middle temporal (Mid.Temp.A.), and posterior temporal arteries (Post.Temp.A.).

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    Classification of the cortical areas used in this study (see references 18 and 19). The territory of the middle cerebral artery is divided into 12 areas: orbitofrontal (Orb.Fr.), prefrontal (Pre.Fr.), precentral (Pre.Cent.), central (Cent.), anterior parietal (Ant.Par.), posterior parietal (Post.Par.), angular (Ang.), temporo-occipital (Temp.Occ.), posterior temporal (Post.Temp.), middle temporal (Mid.Temp.), anterior temporal (Ant.Temp.), and temporopolar (Temp.Pol.).

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    Branching patterns of the middle cerebral artery. The main trunk divided in a bifurcation in 78% of hemispheres and in a trifurcation in 12%. In the remaining 10% the main trunk divided into multiple (four or more) branches. Upper Left: Bifurcation: equal trunk pattern (18% of hemispheres). The main trunk divides into superior (red) and inferior (blue) trunks that are of approximately the same diameter and supply cortical areas of a similar size. The superior trunk supplies the frontal and parietal areas, and the inferior trunk supplies the temporal and temporo-occipital areas. Upper Right: Bifurcation: inferior trunk dominant (32% of hemispheres). The inferior trunk (blue) has a larger diameter and area of supply than the superior trunk (red). The inferior trunk supplies the temporal, occipital, and parietal areas, and the superior trunk supplies the frontal areas. Center Left: Bifurcation: superior trunk dominant (28% of hemispheres). The superior trunk (red) has the largest diameter and area of supply; it supplies the frontal, parietal, temporo-occipital, and posterior temporal areas, and the smaller inferior trunk (blue) supplies the temporopolar through the middle temporal areas. Center Right: Trifurcation pattern (12% of hemispheres). The main trunk of the middle cerebral artery divides into three trunks. The superior trunk (red) supplies the frontal areas, the middle trunk (yellow) supplies the areas around the posterior end of the Sylvian fissure, and the inferior trunk (blue) supplies the temporal areas. Lower Right: Multiple trunks (10% of hemispheres). The main trunk gives rise to multiple smaller trunks. Two trunks supply the frontal areas (red and yellow), two supply the parietal areas (light green and dark green), and three supply the temporal and occipital areas (purple, brown, and blue).

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    Branching patterns of the middle cerebral artery (MCA). These drawings of MCA's dissected from five cerebral hemispheres show the different branching patterns of the main trunk. The main trunk divided in a bifurcation in 78% of hemispheres, in a trifurcation in 12%, and in a multiple branch pattern (four or more trunks) in 10%. The drawings show the main (Main Tr.), superior (Sup.Tr.), middle (Mid.Tr.) and inferior (Inf.Tr.) trunks. These trunks give rise to the lenticulostriate (Len.Str.A.), orbitofrontal (Orb.Fr.A.), prefrontal (Pre.Fr.A.), precentral (Pre.Cen.A.), central (Cent.A.), anterior parietal (Ant.Par.A.), posterior parietal (Post.Par.A.), angular (Ang.A.), temporo-occipital (Temp.Occ.A.), posterior temporal (Post.Temp.A.), middle temporal (Mid.Temp.A.), anterior temporal (Ant.Temp.A.), and temporopolar (Temp.Pol.A.) arteries. Upper Left: Bifurcation: equal trunks (18% of hemispheres). The main trunk divides into superior and inferior trunks that are of approximately the same diameter and supply cortical areas of similar size. The superior trunk gives rise to the orbitofrontal arteries through the angular arteries, and the inferior trunk gives rise to the temporopolar through the temporo-occipital arteries. Upper Right: Bifurcation: inferior trunk dominant (32% of hemispheres). The inferior trunk has a larger diameter and area of supply than the superior trunk. The superior trunk supplies the orbitofrontal through the anterior parietal areas, and the inferior trunk supplies the posterior parietal through the temporopolar areas. Center Left: Bifurcation: superior trunk dominant (28% of hemispheres). The superior trunk has a larger diameter and area of supply than the inferior trunk. It supplies the orbitofrontal through the temporo-occipital areas, and the inferior trunk supplies the temporal areas except for the temporopolar area which is supplied by an early branch (Early Br.) that arises from the main trunk. Center Right: Trifurcation pattern (12% of hemispheres). The main trunk of the MCA divides into three trunks. The superior trunk supplies the orbitofrontal and prefrontal areas, the middle trunk supplies the precentral through the posterior parietal areas, and the inferior trunk supplies the angular through the anterior temporal areas. The temporopolar artery arises from the main trunk as an early branch. Lower Right: Multiple trunks (10% of hemispheres). The main trunk gives rise to more than three trunks. There are five trunks in the specimen shown.

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    Stem artery patterns. The stem arteries arise from the trunks and give rise to the cortical arteries. The central illustration shows the lateral surface of a left cerebral hemisphere with a space between the frontal, parietal, and temporal areas. The frontal lobe is formed by the orbitofrontal (Orb.Fr.), prefrontal (Pre.Fr.), precentral (Pre.Cent.), and the central (Cent.) areas; the parietal lobe is composed of the anterior parietal (Ant.Par.), posterior parietal (Post.Par.), and angular (Ang.) areas; the temporal and occipital lobes are formed by the temporopolar (Temp. Pol.), anterior temporal (Ant.Temp.), middle temporal (Mid.Temp.), posterior temporal (Post.Temp.), and temporo-occipital (Temp.Occ.) areas. The posterior part of the central area, which is actually part of the parietal lobe, is included with the frontal lobe. The central diagram shows the most common stem pattern, and the peripheral diagrams show the next three most common patterns. Each color or shade of a color shows the area supplied by one stem artery. The percentage of hemispheres having the stem pattern shown is listed on each diagram. The most common frontal lobe pattern involves two stem arteries: one gives rise to the branches to the orbitofrontal, prefrontal, and precentral areas, and the other supplies the central area. The most common parietal lobe pattern involves three stem arteries, one each for the anterior and posterior parietal and the angular areas. The most common temporal and occipital lobe pattern involves four stem arteries: one stem artery supplies both the temporopolar and the anterior temporal areas, and there is one stem each for the middle temporal, posterior temporal, and temporo-occipital areas. The next three most common stem patterns for each lobe are shown on the peripheral diagrams. The four patterns shown for each lobe do not account for 100% of the hemispheres, but show only the four most common patterns for that lobe.

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    Cortical branches of the middle cerebral artery exposed by removing the cranial cap. Upper Left: Lateral view of right cerebral hemisphere showing standard points used in tabulating the results of this study. The distances between three standard points on the cortex, called A, B, and C, and the proximal end of the segment of each cortical artery that lay on the cortical surface and would have been accessible for an extracranial to intracranial artery bypass, were measured. Point A was located at the anterior end of the Sylvian fissure (Sylv.Fiss.) where the stem, the anterior horizontal (Ant.Hor.Ramus), anterior ascending (Ant.Asc. Ramus), and posterior (Post.Ramus) rami joined. Point B was located at the posterior end of the Sylvian fissure where the supramarginal gyrus wrapped around the posterior ramus. Point C was located at the intersection of a line drawn through Points A and B with a line beginning at the external auditory canal and drawn perpendicular to the canthomeatal line (the line between the lateral canthus of the eye and the external auditory canal). Point C varied from 17 mm anterior to 19 mm posterior to Point B (average, 2.3 mm posterior to Point B). Point C was located posterior to Point B in 50% of hemispheres and anterior in 22%. The two points (B and C) were located within 1 mm of each other in the remaining 28% of hemispheres. The relationship of the cortical arteries to several points on the canthomeatal line, called D and E, was also examined. Point E was located where a line drawn perpendicular to the canthomeatal through Point B crossed the canthomeatal line. Point D was located where a line drawn perpendicular to the canthomeatal line through Point A crossed the canthomeatal line. The arteries supplying the 12 cortical areas usually exit the Sylvian fissure along the line connecting Points A and B, and in that case a measurement between Points A, B, and C and the proximal end of the cortical artery would be along line AB (Table 2). However, some cortical arteries exited the Sylvian fissure in a sulcus and did not appear on the surface for a variable distance above or below the Sylvian fissure, and, in those cases, the measurement would be between the three points and the site at which the cortical artery appeared on the surface, rather than along the line connecting Points A and B. The vessels exiting the Sylvian fissure nearest Point A were the orbitofrontal (Orb.Fr.A.), prefrontal (Pre.Fr.A.), temporopolar (Temp. Pol.A.), and anterior temporal (Ant.Temp.A.) arteries; the vessels arising nearest to Point C were the anterior parietal (Ant.Par.A.), posterior parietal (Post.Par.A.), angular (Ang.A.), and temporo-occipital (Temp.Occ.A.) arteries. The latter group of arteries located at the posterior end of the Sylvian fissure included the three largest cortical arteries. The precentral (Pre.Cent.A.), central (Cent.A.), middle temporal (Mid.Temp.A.), and posterior temporal (Post.Temp.A.) arteries exited the fissure between Points A and B. The stem of the Sylvian fissure (Sylv.Fiss.) extended medially along the sphenoid ridge. The part of the Sylvian fissure on the surface divides into three rami: the anterior horizontal (Ant.Hor.Ramus), anterior ascending (Ant.Asc.Ramus), and the posterior (Post.Ramus) rami. The sphenoid ridge terminates at the junction of these three rami with the stem of the Sylvian fissure. The central sulcus (Cent.Sul.) separates the frontal and parietal lobes. The posterior temporal artery is the largest cortical branch on the surface of this hemisphere. Upper Right: Lateral view of another right cerebral hemisphere showing the relationship of the 12 cortical arteries to the Sylvian fissure and cerebral convexity. Lower Right: Left cerebral hemisphere. The branches of the anterior cerebral artery (A.C.A.) extend from the medial to the lateral surface of the cerebral hemisphere in the region of the superior frontal gyrus.

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    Drawing of the lateral view of the left cerebral hemisphere showing the standard points used in tabulating the results of this study. The distances between the points are listed in the table below the drawing. Point A was located at the anterior end of the Sylvian fissure where the stem, the anterior horizontal, anterior ascending, and posterior rami joined. The lateral end of the sphenoid ridge is also located at or near Point A. The “keyhole,” another standard point used in planning a bone flap for a craniotomy, is shown. The “keyhole” is located just behind the junction of the temporal line and the zygomatic process of the frontal bone, 1 to 2 cm anterior to the pterion. A burr hole located here will expose the dura over the lower part of the frontal lobe in its upper half and the periorbita in its lower half. Point B was located at the posterior end of the Sylvian fissure where the supramarginal gyrus wrapped around the posterior ramus. Point C was located at the intersection of a line drawn through Points A and B, with a line beginning at the external auditory canal and drawn perpendicular to the canthomeatal line (the line between the lateral canthus of the eye and the external auditory canal). Point C varied from 17 mm anterior to 19 mm posterior to Point B (average, 2.3 mm posterior to Point B). Point C was located posterior to Point B in 50% of hemispheres and anterior in 22%. Points B and C were located within 1 mm of each other in the remaining 28% of hemispheres. Point D was located where a line drawn perpendicular to the canthomeatal line through Point A crossed the canthomeatal line. Point E was located where a line drawn perpendicular to the canthomeatal through Point B crossed the canthomeatal line. The distance between the proximal part of the cortical arteries and Points A, B, and C is shown in Table 4.

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