Microsurgical Anatomy of The Temporal Lobe Part.1

ANATOMY
Surgical Anatomy
MICROSURGICAL ANATOMY OF THE TEMPORAL LOBE:

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PART 2—SYLVIAN FISSURE REGION AND

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ITS CLINICAL APPLICATION

Hung Tzu Wen, M.D. OBJECTIVE: We present observations of the anatomy of the sylvian fissure region and
Department of Neurological Surgery, their clinical application in neuroimaging, microsurgery for middle cerebral artery
University of Florida, aneurysms and insular lesions, frontobasal resections, and epilepsy surgery.
Gainesville, Florida, and
Division of Neurosurgery, METHODS: Sixty adult cadaveric hemispheres and 12 adult cadaveric heads were stud-
Hospital das Clínicas, ied after perfusion of the arteries and veins with colored latex. The anatomic informa-
University of São Paulo;
Hospital Samaritano,
tion was applied in more than 200 microsurgeries in and around the sylvian fissure
São Paulo, Brazil region in the past 15 years.
IJoHU/fzMAptn on 03/21/2023
RESULTS: The sylvian fissure extends from the basal to the lateral surface of the brain
Albert L. Rhoton, Jr., M.D. and presents 2 compartments on each surface, 1 superficial (temporal stem and its
Department of Neurological Surgery, ramii) and 1 deep (anterior and lateral operculoinsular compartments). The temporal
University of Florida,
Gainesville, Florida operculum is in opposition to the frontal and parietal opercula (planum polare versus
inferior frontal and precentral gyri, Heschl’s versus postcentral gyri, planum temporale
Evandro de Oliveira, M.D. versus supramarginal gyrus). The inferior frontal, precentral, and postcentral gyri cover
Department of Neurological Surgery, the anterior, middle, and posterior thirds of the lateral surface of the insula, respec-
University of Florida, tively. The pars triangularis covers the apex of the insula, located immediately distal to
Gainesville, Florida
the genu of the middle cerebral artery. The clinical application of the anatomic infor-
Luiz Henrique M. Castro, M.D.
mation presented in this article is in angiography, middle cerebral artery aneurysm sur-
Department of Neurology,
gery, insular resection, frontobasal resection, and amygdalohippocampectomy, and
Hospital das Clínicas, hemispherotomy.
University of São Paulo; CONCLUSION: The anatomic relationships of the sylvian fissure region can be help-
Hospital Samaritano,
São Paulo, Brazil ful in preoperative planning and can serve as reliable intraoperative navigation landmarks
in microsurgery involving that region.
Eberval Gadelha Figueiredo, M.D. KEY WORDS: Aneurysm, Heschl’s gyrus, Insula, Microsurgical anatomy, Middle cerebral artery, Sylvian fis-
Division of Neurosurgery, sure, Temporal lobe
Hospital das Clínicas,
University of São Paulo, Neurosurgery 65[ONS Suppl 1]:ons1–ons36, 2009 DOI: 10.1227/01.NEU.0000336314.20759.85
São Paulo, Brazil
Manoel Jacobsen Teixeira, M.D.
T
Division of Neurosurgery, he sylvian fissure is the most prominent on the anatomy of the sylvian fissure could be
Hospital das Clínicas, and complex fissure of the brain, and the added to the literature.
University of São Paulo, surgical approaches through the sylvian We work in academic institutions and have
São Paulo, Brazil
fissure are among the most popular approaches observed that with the advances in imaging
in contemporary neurosurgery (28, 31, 32, and targeting technologies over the years, the
Reprint requests:
Hung Tzu Wen, M.D., 34–36). capacity of younger neurosurgeons to interpret
Email: [email protected] Although some of the pertinent anatomy of angiography has diminished drastically. Also,
the sylvian fissure and its contents have been it is sometimes difficult, especially for novice
Received, May 17, 2008. described previously (5, 10, 12–14, 19, 20, 22, surgeons, to process, convert, and apply the
Accepted, August 25, 2008. 25, 30, 34), we believe that different viewpoints complex anatomic information in their daily
neurosurgical practice.
Copyright © 2009 by the
Congress of Neurological Surgeons Therefore, in this article, after a brief review
ABBREVIATIONS: AP, anteroposterior; CT, com- of the current concept of the sylvian fissure,
puted tomographic; MCA, middle cerebral artery;
we display some additional observations on
MRI, magnetic resonance imaging
the anatomy of the sylvian fissure region and
NEUROSURGERY VOLUME 65 | OPERATIVE NEUROSURGERY 1 | DECEMBER 2009 | ons1

WEN ET AL.
demonstrate some of the clinical applications of that anatomic

knowledge in the first author’s (HTW) microneurosurgical
practice over the past 15 years.
ANATOMIC CONSIDERATIONS
The sylvian fissure is a fissure formed by the infolding of the

frontal, parietal, and temporal opercula over the insula. The
insula has been described as a pyramid-shaped structure with its
apex pointing downward, surrounded by the superior, inferior,
and anterior limiting or circular sulci (20, 22, 30). It presents lat-
eral and anterior surfaces. The lateral surface of the insula is
divided by the central sulcus of the insula into a larger anterior
zone and a small posterior zone. The anterior zone is composed
of the anterior, middle, and posterior short gyri that converge and
fuse with each other in the apex of the insula, which is the most
convex or prominent portion of the insula. The posterior zone
usually consists of one long gyrus that bifurcates posteriorly. The
long gyrus courses anteroinferiorly to reach the most anteroinfe-

rior aspect of the insula pole.
The anterior surface of the insula is composed of one vertically
oriented and laterally placed gyrus, an accessory gyrus, and a
short transversely oriented and medially placed gyrus, the trans-
verse gyrus of Eberstaller. Both gyri converge inferiorly and
become fused with each other at the insular pole. The insular pole
is exclusively derived from the gyri originating from the anterior
zone and from the anterior surface of the insula. The limen insu- FIGURE 1. Superior view of the left temporal lobe. 1,
cuneus; 2, posterior transverse temporal gyrus; 3,
lae or the falciform fold is composed of fibers of uncinate fascicu-
parahippocampal gyrus; 4, middle transverse temporal
lus covered by a thin layer of gray matter that presents itself as an
gyrus; 5, Heschl’s gyrus (anterior transverse temporal
arched ridge of variable prominence extending from the anterior gyrus); 6, head of the hippocampus; 7, planum polare;
end of the long gyrus, where it fuses with the temporal pole, pass- 8, anteromedial surface of the uncus; 9, superior tempo-
ing through the medial part of the insular pole, and ends at the ral gyrus, where the anterior portion of the temporal
middle of the posterior orbital gyrus. lobe starts to deviate medially.
The temporal operculum that constitutes the inferior wall of
the sylvian fissure is the superior surface of the temporal lobe. It
comprises, from posterior to anterior, the planum temporale, Sylvian Fissure
Heschl’s gyrus, and planum polare.
The planum temporale is usually composed of 2 transverse According to Gibo et al. (5), the sylvian fissure presents a
temporal gyri: the middle and the posterior. The planum tem- superficial part and a deep part: the sylvian fissure stem and the
porale is a flat, triangular-shaped area with its apex pointing 3 main rami (anterior horizontal, anterior ascending, and poste-
medially. rior rami) form the superficial part. The stem is located on the
The Heschl’s gyrus or anterior transverse temporal gyrus is basal surface, and the 3 rami are located on the lateral surface.
located anterior to the planum temporale and is separated The sphenoidal and the operculoinsular compartments of the
from the latter by the Heschl’s sulcus. The Heschl’s gyrus is sylvian fissure form the deep part. The sphenoidal compartment
directed medially to laterally and posteriorly to anteriorly, is located on the basal surface, and the operculoinsular is located
and it is fused with the superior temporal gyrus on the lateral on the lateral surface.
surface of the cerebrum. Szikla et al. (19) also described the sylvian fissure in a similar
The planum polare is a depression that constitutes the supe- way, but with different terminology: superficial, intermediate, and
rior surface of the anterior portion of the temporal lobe; it is deep planes. The superficial plane corresponds to that described
located between the Heschl’s gyrus posteriorly and the uncus by Gibo et al. (5), the intermediate plane matches the opercular
anteromedially (Fig. 1A). compartment, and the deep plane is the insular compartment.
The gyri of the frontal lobe that constitute the sylvian fissure The sylvian fissure stem starts just lateral to the anterior per-
are lateral and posterior medial orbital gyri on the basal surface forated substance, between the lateral olfactory stria and the rhi-
of the hemisphere and the pars orbitalis, triangularis, pars nal incisura or temporal incisura (10, 22, 30), and proceeds later-
opercularis, and precentral gyrus on the lateral surface. The ally and anteriorly toward the lateral surface of the brain. During
gyri of the parietal lobe that constitute the sylvian fissure are this trajectory, it stays behind the lesser wing of the sphenoid
postcentral and supramarginal gyri. bone. The temporal stem is covered anteriorly by the arachnoid
ons2 | VOLUME 65 | OPERATIVE NEUROSURGERY 1 | DECEMBER 2009 www.neurosurgery-online.com

SYLVIAN FISSURE REGION ANATOMY
membrane, the frontotemporal arachnoid reflection that covers vessels injected with colored latex were dissected in the microneurosur-
the frontal lobe, and continues on the surface of the temporal gical anatomy laboratory at the Department of Neurological Surgery,
lobe (30). University of Florida, for photographic documentation. Subsequently,
On the lateral surface of the cerebrum, the stem of the sylvian between 1996 and 1998, 60 additional formalin-fixed adult cadaveric
hemispheres were dissected in the microsurgery laboratory at the
fissure divides into the anterior horizontal, anterior ascending,

Hospital Beneficência Portuguesa, São Paulo, Brazil, for additional
and posterior rami. The anterior horizontal and the anterior
observation.
ascending rami delimit the pars triangularis of the inferior The lessons learned from the anatomic laboratory studies were
frontal gyrus. The junction of these 3 rami is located at the tip applied in more than 200 surgeries using transsylvian approaches per-
of the pars triangularis. The posterior ramus of the sylvian fis- formed from 1996 to 2007 by a single surgeon (HTW) at the Hospital
sure is the longest one; it is directed posteriorly and superiorly, das Clínicas, College of Medicine, University of São Paulo, and the
separating the frontal and parietal lobes superiorly from the Hospital Samaritano, in São Paulo, Brazil.
temporal lobe inferiorly. The sphenoidal compartment arises in
the region of the limen insulae at the lateral margin of the ante- RESULTS
rior perforated substance. It is a narrow space posterior to the
sphenoid ridge between the frontal and temporal lobes that Additional Anatomic Observations
communicates medially with the carotid cistern. The opercu-
loinsular compartment is located deep to the superficial rami of Temporal Operculum
the sylvian fissure on the lateral surface. The junction between the Heschl’s gyrus and the superior
The intermediate or opercular compartment of the sylvian temporal gyrus usually occurs in the coronal plane at the level
fissure is composed of the opercula from the frontal and pari- of the external acoustic meatus (Fig. 2, A and B). This junctional
etal lobes superiorly and those from the temporal lobe inferi- point is usually not very evident on the surface of the cerebrum,
orly. The pars orbitalis also is called the fronto-orbital opercu- making its intraoperative identification difficult. However, the
lum; the pars triangularis is called the frontal operculum; pars Heschl’s gyrus can be promptly identified on its opercular por-
opercularis, and the precentral and postcentral gyri are collec- tion because of its characteristic hump (Fig. 2C). Medially, the
tively called frontoparietal operculum; and the supramarginal Heschl’s gyrus is directed toward the pulvinar of the thalamus,
gyrus is called the parietal operculum (2). and it constitutes the posterior wall of the retroinsular space.
Yaşargil et al. (31) described an intraoperative finding of 4 The planum polare can be divided into 2 parts: the first part
different types of the intermediate plane of the anterior syl- extends from the Heschl’s gyrus to the level of the anterior
vian fissure. edge of the precentral gyrus and presents its main axis ori-
The insular compartment described by both Szikla et al. (19) ented anteroposteriorly. The second part starts at the level of
and Gibo et al. (5) is located on the lateral surface of the insula. the anterior edge of the precentral gyrus, soon deviates medi-
The insular compartment contains the M2 segment of middle ally like the rest of the anterotemporal structures, and has its
cerebral artery (MCA) and insular veins. axis oriented lateromedially. This medial deviation is more evi-
The MCA is divided into 4 segments. The M1 segment dent from the level of the pars triangularis (Fig. 2, A and D).
extends from the carotid bifurcation to the limen of the insula The medial deviation of the planum polare in addition to
(31) or to the genu of the MCA (5, 13). The M2 segment turns the usual upward retraction of the pars triangularis leaves a
around the pole of the insula to form the genu of the MCA and formidable space in the lateral sylvian fissure (Fig. 2A).
continues on the lateral surface of the insula to reach the supe- The Heschl’s gyrus and the planum temporale form a trian-
rior and inferior limiting sulci. It then turns downward to fol- gular area with its apex pointing medially toward the retroin-
low the inner surface of the frontal, parietal, and temporal sular region, the posterior portion of the posterior limb, and the
opercula to become the M3 segment, which runs between the retrolentiform parts of the internal capsule. The apex of that
frontal and parietal opercula above and the temporal opercu- area also points indirectly toward the atrium of the lateral ven-
lum below. The M4 segment exits the sylvian fissure to consti- tricle and toward its anterior wall, which is the ventricular por-
tute the cortical branches of the MCA. tion of the pulvinar of the thalamus (Fig. 2E).
During its trajectory on the lateral surface of the insula, the
M2 segment sends off branches to the insula, extreme capsule, Fronto-orbital Operculum
and occasionally the claustrum and the external capsule. The The pars orbitalis of the inferior frontal gyrus occupies not
lenticulostriate arteries supply the structures of the central core only the lateral surface of the cerebrum, but also the most lateral
of the hemisphere located medially to the claustrum (12, 26). At and most posterior aspect of the orbital surface of the frontal
the posterior portion of the insula, the M2 segment can send off lobe, formed by the posterior part of the lateral orbital gyrus
branches the corona radiata (23). and the lateral part of the posterior orbital gyrus (Fig. 3).
Parietal Opercula
MATERIALS AND METHODS The postcentral gyrus consistently overlies the Heschl’s gyrus
The anatomic part of the study was performed in 2 locations: (anterior transverse temporal gyrus). The precentral gyrus, pars
between 1993 and 1996, 12 formalin-fixed adult cadaveric heads with opercularis, and pars triangularis are in opposition to the

WEN ET AL.
planum polare, and the supra-

A B marginal gyrus (composed of
middle and posterior trans-
verse parietal gyri) overlies
the planum temporale (com-

posed of middle and posterior
transverse temporal gyri)

(Figs. 2, B and C, and 4, A–F).
When viewed from the
front, the transverse diameter
of the poles of the frontal and
occipital lobes is smaller than
that of the parietal lobe. In a
person with a normal cranial
configuration, the largest trans-
verse diameter of the cerebrum
C D on an anteroposterior (AP)
view is located at the level of

the postcentral gyrus in the
suprasylvian region and at the
level of the middle or superior
temporal gyrus in the infrasyl-
vian region, on the same cor-
onal plane as the postcentral
gyrus (Fig. 4, A, E, and G).
Sylvian Fissure
The frontotemporal arach-
noid membrane covers the
basal surface and the lateral
surface of the cerebrum. On
FIGURE 2. A, lateral view of the left cerebral hemisphere. 1, pars E the basal surface, the fron-
triangularis of the inferior frontal gyrus; 2, precentral gyrus; 3, totemporal arachnoid mem-
postcentral gyrus; 4, supramarginal gyrus; 5, pars orbitalis; 6, pars brane bridges the anterior por-
opercularis; 7, junction between the superior temporal gyrus and the tion of the planum polare to
Heschl’s gyrus; 8, external acoustic meatus. Asterisk, at this point, the posterior portion of the lat-
the planum polare starts to deviate medially. Note the large space in eral, posterior, and medial
the sylvian fissure between the structures 1, 5, and 6. B, sagittal orbital gyri (Fig. 5A). It contin-
magnetic resonance imaging (MRI) scan at the surface of the left ues medially with the arach-
hemisphere. 1, postcentral gyrus. Asterisk, projection of the external
noidal membrane of the
acoustic meatus over the petrous temporal bone. Heschl’s gyrus
carotid, olfactory, and chias-
(arrow). C, sagittal MRI scan at the opercular level of the left hemi-
sphere. 1, postcentral gyrus. Asterisk, projection of the external matic cisterns (Fig. 5B).
acoustic meatus over the petrous temporal bone. Heschl’s gyrus The sylvian fissure divides
(arrow). D, anterobasal view of the cerebrum. 1, pars triangularis; into 3 rami (horizontal, ante-
2, pars orbitalis; 3, pars opercularis; 4, precentral gyrus. The large rior ascending, and posterior)
arrow indicates where the medial deviation of the planum polare at the level of the tip of the
begins. The small arrow indicates where the medial deviation of the pars triangularis. The transi-
planum polare intensifies. E, superior view of the left hemisphere. tion between the basal and lat-
An axial cut has been made to expose the lateral ventricle. The eral parts of the sylvian fissure
frontal and parietal opercula have been removed to expose the insula
can therefore be considered as
and the temporal opercula. 1, rostrum of the corpus callosum; 2,
located at the level of the pars
head of the caudate nucleus; 3, planum polare; 4, insula; 5, thala-
mus; 6, Heschl’s gyrus; 7, choroid plexus of the atrium of the lateral triangularis of the inferior
ventricle covering the pulvinar of the thalamus; 8, middle transverse temporal gyrus; 9, posterior transverse temporal frontal gyrus.
gyrus. The arrow indicates the medial end of the Heschl’s gyrus that points toward the posterior limb of the internal cap- There is an intermediate
sule and toward the atrium of the lateral ventricle. The arrowheads indicate the location of the angiographic sylvian point. plane, as stated by Szikla et al.
(19), on the basal surface of

is located on the superior temporal gyrus and begins at the

level of the posterior margin of the pars opercularis, but the
planum polare has its medial curve intensified from the level of
the tip of the pars triangularis.
The planum polare therefore presents 2 distinct morpholo-

gies. The first, the posterior part, extends from the Heschl’s
gyrus to the “turning point” located at the level of the pars

opercularis but becomes more evident at the level of the pars
triangularis. It is related to the precentral gyrus, pars opercu-
laris, and pars triangularis of the inferior frontal gyrus. The
second, the anterior part, extends from the level of the pars tri-
angularis to the rhinal incisura that separates the planum
polare from the uncus. This part of the planum polare consti-
tutes the pole of the temporal lobe located under the lesser
wing and behind the greater wing of the sphenoid. It is related
to the lateral and posterior orbital gyri.
The anterior horizontal ramus of the sylvian fissure contin-
ues medially as the anterior limiting sulcus of the insula (Fig.

5D). The anterior horizontal ramus separates the pars orbitalis
anteriorly from the pars triangularis posteriorly. As mentioned
previously, the pars orbitalis occupies both basal and lateral
surfaces of the cerebrum; it is composed of the posterior por-
tion of the lateral orbital gyrus and the lateral portion of the
posterior orbital gyrus. The anterior horizontal ramus therefore
FIGURE 3. Basal view of the right hemisphere. The separates the pars triangularis from the pars orbitalis and the
temporal operculum has been removed to expose the lateral orbital gyrus.
frontal and parietal opercula. 1, lateral orbital gyrus; 2,
anterior orbital gyrus; 3, medial orbital gyrus; 4, poste- Insula
rior orbital gyrus; 5, rectus gyrus; 6, pars triangularis; The lateral surface of the insula is convex and presents 2
7, pars opercularis; 8, precentral gyrus; 9, postcentral
facets: superolateral and inferolateral. This distinction is more
gyrus; 10, supramarginal gyrus. Asterisk, pars orbitalis.
evident in the anterior zone of the insula. These 2 facets are
divided by an edge that we called the insular edge in this study.
The superolateral facet is composed of short gyri (anterior, mid-
the anterior portion of the cerebral hemisphere. It is located dle, and posterior), the central sulcus, the upper part of the
between the opercular portions of the lateral and posterior anterior long gyrus, the insular apex, and the edge between the
orbital gyri on the frontal side and the upper part of the ante- anterior short gyrus and the transverse gyrus of Eberstaller
rior portion of the planum polare on the temporal side. that occupies the inferior portion of the anterior surface of the
The deep part of the sylvian fissure on the basal surface is insula. The superolateral facet of the insula is related to the
not restricted only to the narrow space posterior to the sphe- operculum of the pars triangularis, pars opercularis, and pre-
noid ridge between the frontal and temporal lobes, in front of central and postcentral gyri. The superior lateral insular cleft is
the insular pole, but it extends upward over the anterior sur- the space between the superolateral facet of the insula and the
face of the insula, between the posterior surfaces of the lateral, frontal and parietal opercula (Fig. 6A).
posterior, and medial orbital gyri anteriorly and the anterior The inferolateral facet of the insula comprises the inferior
surface of the insula. Because this part of the sylvian fissure is portion of the anterior and posterior long gyri that continue
related to the anterior surface of the insula, we named this part anteriorly and inferiorly toward the lateral edge of the anterior
of the sylvian fissure the anterior operculoinsular compart- pole of the insula, the basal continuation of the short gyri of the
ment. The sphenoidal compartment is the inferior portion of superolateral facet of the insula below the insular edge com-
the anterior insular compartment, and it is related to the lesser prises the transverse gyrus of Eberstaller. The basal continua-
wing of the sphenoid bone (Fig. 5C). We also renamed the oper- tion of the short gyri courses inferomedially toward the super-
culoinsular compartment on the lateral surface of the cerebrum omedial portion of the insular pole, just lateral to the lateral
the lateral operculoinsular compartment. olfactory striae. The anterior portion of the inferolateral facet is
When viewed from its basal surface, the axis of the temporal actually the base of the anterior surface of the insula. The pos-
lobe is initially directed posteriorly to anteriorly, completely terior edge of the medial orbital gyrus and the medial edge of
covering the parietal operculum. At its anterior portion, the the posterior orbital gyrus, collectively called the posteromedial
temporal lobe turns medially, having its tip moved under the lobule (22), and the medial end of the transverse gyrus of the
posterior orbital gyrus (Fig. 2D). The turning point of this curve insula meet just anterior to the lateral olfactory striae, lateral to

WEN ET AL.
A B
C
FIGURE 4. A, superolateral view of the left hemisphere. 1, precentral gyrus;

2, postcentral gyrus; 3, supramarginal gyrus; 4, inferior frontal sulcus; 5, pars
opercularis of the inferior frontal gyrus; 6, superior temporal gyrus; 7, pars tri-
angularis of the inferior frontal gyrus. The arrows indicate the ascending and
descending terminal branches of the posterior ramus of the sylvian fissure. The
arrowhead indicates posterior ramus of the sylvian fissure. The largest trans-
verse diameter of the cerebrum usually corresponds to the level of postcentral
gyrus and to the middle and the superior temporal gyri (at the level of the post-
central gyrus). B, superolateral view of the same specimen shown in A. A
transverse cut has been made by following a line drawn from the base of the
pars triangularis of the inferior frontal gyrus to the supramarginal gyrus,
immediately above the posterior ramus of the sylvian fissure. 1, frontal horn;
2, head of the caudate nucleus; 3, atrium; 4, pars triangularis; 5, pars opercu-
laris; 6, precentral gyrus; 7, postcentral gyrus; 8, supramarginal gyrus; 9,
superior temporal gyrus. C, the operculum of the supramarginal gyrus has
been removed to display the middle and posterior transverse temporal gyri and branch of the posterior ramus of the sylvian fissure to become the supramar-
the medial end of the Heschl’s gyrus. 1, medial part of the Heschl’s gyrus (ante- ginal gyrus; 7, superior temporal gyrus. The supramarginal gyrus consti-
rior transverse temporal gyrus); 2, middle transverse temporal gyrus; 3, pos- tutes the posterior wall of the posterior ramus of the sylvian fissure. D, the
terior transverse temporal gyrus; 4, precentral gyrus; 5, postcentral gyrus; 6, operculum of the postcentral gyrus has been removed to display the Heschl’s
posterior end of the superior temporal gyrus turning around the descending gyrus and posterior end of the insula. 1, posterior long gyrus of (Continues)

the insula; 2, Heschl’s gyrus; 3, middle transverse temporal gyrus; 4, poste- F, the pars opercularis of the inferior frontal gyrus has been removed to dis-
rior transverse temporal gyrus; 5, pars opercularis; 6, precentral gyrus; 7, play the anterior portion of the planum polare and the anterior portion of the
supramarginal gyrus; 8, superior temporal gyrus. E, the operculum of the pre- insula. 1, insula; 2, pars triangularis; 3, Heschl’s gyrus; 4, planum polare. G,
central gyrus has been removed to display the posterior part of the planum frontal view of the cerebrum. The largest transverse diameter of the brain in
polare, located immediately anterior to the Heschl’s gyrus, and also to display the suprasylvian region corresponds to the postcentral gyrus (large arrows).
the posterior half of the insula. 1, posterior insula; 2, pars triangularis; 3, pars The largest transverse diameter of the brain in the infrasylvian region corre-
opercularis; 4, Heschl’s gyrus; 5, middle transverse temporal gyrus; 6, poste- sponds to the superior or middle temporal gyrus, in the coronal plane of the
rior transverse temporal gyrus; 7, planum polare; 8, superior temporal gyrus. postcentral gyrus (small arrows).
the olfactory tract (Fig. 6B). The inferior lateral insular cleft is The anterior surface of the insula is triangular in shape and
the space between the inferolateral facet of the insula and the composed of an anterior short gyrus, an accessory gyrus, and
temporal operculum. the transverse gyrus of Eberstaller. The transverse gyrus contin-
ues with the part of the ante-
A B rior short gyrus that is located
at the inferolateral facet. The
medial limit of the anterior
surface of the insula is the
anterior limiting sulcus (Fig.

6C). The anterior insular cleft
is the space between the ante-
rior surface of the insula and
the posterior and lateral
orbital gyri. The overall rela-
tionship between the anterior
surface and the inferolateral
facet of the insula is shown in
Figure 6D.
Therefore, the insula pres-
C D ents a rather complex shape.
The anterior portion of the in-
sula is marked by a prominent
edge sharply dividing the su-
perolateral and inferolateral
facets; the latter presents a
somewhat horizontal obliquity,
almost parallel to the floor in
the anatomic position (Fig. 6E).
The insular edge is less promi-
nent in the posterior portion of
the insula: the surface of the
posterior insula is slightly con-
vex, almost perpendicular to
the floor in the anatomic posi-
FIGURE 5. A, anterobasal view of the cerebrum. The arrowheads indicate the frontotemporal arachnoid reflection
bridging the orbital surface of the frontal lobe to the planum polare. 1, anterior orbital gyrus; 2, lateral orbital gyrus; tion (Fig. 6F).
3, rectus gyrus; 4, posterior orbital gyrus; 5, medial orbital gyrus. B, intraoperative photograph showing the basal The middle portion of the
surface of the right hemisphere after the pterional craniotomy and dural opening. The frontotemporal arachnoid mem- insula represents a transitional
brane (arrows) in this figure has been stretched between the tip of the bipolar forceps and the suction tube. The fron- zone between the anterior and
totemporal arachnoid membrane is continuous with the carotid, chiasmatic, and olfactory cisterns. In this figure, the posterior portions: the insular
olfactory tract is shown at the right side of the tip of the suction tube, and the optic nerve is shown at the right side edge is still present but less
of the olfactory tract. C, sagittal MRI scan. The arrows indicate the intermediate plane of the sylvian fissure on the prominent (Fig. 6G).
basal surface, located between the posterior portion of the orbital gyri and the planum polare. The arrowheads indi- The classic description of a
cate the anterior operculoinsular compartment of the sylvian fissure. D, superolateral view of the left hemisphere. A
pyramid with its apex point-
spatula has been placed in the horizontal ramus of the sylvian fissure that continues medially with the anterior lim-
ing downward seems to be
iting sulcus of the insula. The precentral gyrus is usually related to the mid-posterior portion of the insula. 1, pre-
central gyrus; 2, frontal horn; 3, anterior limiting sulcus of the insula; 4, junction between the inferior and the supe- more suitable to describe the
rior limiting sulci of the insula; 5, anterior portion of the insula; 6, pars orbitalis; 7, Heschl’s gyrus. shape of the anterior insula,
composed of short gyri and

WEN ET AL.
A B
FIGURE 6. A, lateral view of the right insula. In this specimen, the short verse gyrus of Eberstaller; 1, anterior short gyrus; 2, middle short gyrus; 3,
insular sulcus that separates the anterior and the middle short gyri traverses posterior short gyrus; 2 + 3, fusion of the middle and posterior short gyri; 4,
the insular apex and extends to the limen insulae. 1, anterior short gyrus; 2, anterior long gyrus; 5, posterior long gyrus; IP, insular pole; RI, rhinal
middle short gyrus; 3, posterior short gyrus; 4, anterior long gyrus; 5, pos- incisura; APS, anterior perforated substance; TS, temporal stem; OT, optic
terior long gyrus. The central sulcus of the insula is located between the pos- tract; AM, amygdala; CP, insertion of the choroid plexus at the inferior
terior short gyrus and the anterior long gyrus of the insula. The dotted line choroidal point. Double asterisk, short insular sulcus. The dotted line indi-
indicates the inferior limiting sulcus of the insula. B, basal view of the right cates the inferior limiting sulcus of the insula. Asterisk, medial nucleus of
insula to display the inferolateral facet. In this specimen, the short insular sul- amygdala. The medial nucleus of the amygdala is located anterior and slightly
cus that runs between the anterior and middle short gyri also traverses the superior to the inferior choroidal point, and it is in close proximity to the optic
insular apex and extends to the limen insulae. 0, accessory gyrus; 1ⴕ, trans- tract and the upper part of the crus cerebri. The posteromedial (Continues)

E F
G H
rior short gyrus; 2, middle short gyrus; Caudate N, head of the

caudate nucleus. The dotted line indicates the anterior limiting
sulcus of the insula. The insular edge and the superolateral and
inferolateral facets of the insula are more evident at the anterior
portion of the insula as shown in this figure. D, laterobasal view
of the cerebrum. The posterior orbital gyrus has been removed to
display the overall view of the anterior surface and the inferolateral
facet of the insula. 0, accessory gyrus; 1ⴕ, transverse gyrus of
Eberstaller; 1, anterior short gyrus; 2, middle short gyrus and the
insular apex; 3, posterior short gyrus; 4, insular pole; 5, anterior
long gyrus; 6, posterior long gyrus; 7, horizontal ramus of the syl-
vian fissure; 8, pars triangularis. Asterisk, posteromedial orbital
lobule. The anterior zone of the insula (anterior surface and the
short gyri) forms a pyramidal structure with its apex pointing
laterally and inferiorly. The insular pole and the limen insulae are
orbital lobule is composed of the medial portion of the posterior orbital gyrus located more medially and posteriorly in relation to pars triangularis. E,
and by the posterior portion of the medial orbital gyrus. C, frontal view of the frontal view. A coronal cut has been made at the anterior portion of the insula
right insula. 0, accessory gyrus; 1ⴕ, transverse gyrus of Eberstaller; 1, ante- at the level of the optic nerves. In the anterior portion of the (Continues)

WEN ET AL.
K L
lentiform nucleus is located above the posteromedial orbital lobule and above
the transverse gyrus of Eberstaller and is separated from the latter by a layer
of white matter interposed by the claustrum. 1, head of the caudate nucleus;
2, superior limiting sulcus; 3, foramen of Monro (left); 4, lentiform nucleus
and olfactory sulcus; 5, rectus gyrus; 6, optic nerve and olfactory tract; 7, pos-
terior orbital gyrus; 8, posteromedial orbital lobule. The arrowheads indicate
superior insular cleft and superolateral facet of insula. The white arrow indi-
cates transverse gyrus of Eberstaller. The blue arrow indicates junction
between the transverse gyrus and the posteromedial orbital lobule. IE, insu-
insula, the superolateral and the inferolateral facets, as well as the insular lar edge. Asterisk, paraolfactory gyrus. The red arrowhead indicates claus-
edge, are more evident. In the right hemisphere, the coronal cut includes the trum. The head and body of the caudate nucleus are located more superiorly
extension of the anterior short gyrus in the inferolateral facet, the transverse than the superior limiting sulcus of the insula. G, coronal MRI scan of the
gyrus of Eberstaller, and its junction with the posteromedial orbital lobule posterior portion of the insula. H, coronal MRI scan of the middle portion of
(blue arrow). In the left hemisphere, a coronal cut has been made more ante- the insula. F, laterobasal view of the right insula. 0, accessory gyrus; 1ⴕ,
riorly and included the posterior orbital gyrus. At this level, the head of the transverse gyrus of Eberstaller; 1, anterior short gyrus; 2, middle short gyrus;
caudate is located immediately above the gray matter overlying the olfactory 3, posterior short gyrus; 2 + 3, junction between the middle and the posterior
sulcus and is separated from the latter by a thin layer of white matter. The short gyri; 4, anterior long gyrus; 5, posterior long gyrus; IA, (Continues)
the gyri of the anterior surface (Fig. 6, D and H). The posterior insular, transverse, and accessory gyri; it is shallower in its
insula presents the shape of a long strip that extends from the superior portion. The inferior portion of the anterior insular
retroinsular region, above the insular edge, to the lateral edge of cleft is deeper and extends all the way to the junction between
the insular pole on the inferolateral facet of the insula. the posterior end of the medial orbital gyrus and the postero-
The anterior and lateral walls of the insula are schematically medial end of the posterior orbital gyrus (posteromedial orbital
depicted in Figure 6, I–K. lobule). The inferior portion of the anterior limiting sulcus of
The superomedial limit of the anterior limiting sulcus of the the insula separates the posterior half of the lateral orbital
insula is related to the anterior portion of the anterior limb of gyrus and the posterior orbital gyrus from the transverse gyrus
the internal capsule, which constitutes the most anterior portion of Eberstaller (Fig. 6D).
of the lateral wall of the frontal horn, ahead of the head of the The anterior limiting sulcus and the medial end of the trans-
caudate nucleus (Fig. 2E). verse gyrus are the lateral limit of the posteromedial orbital lob-
The anterior insular cleft separates the posterior surface of ule, which can clearly be identified as having the shape of the
the lateral and posterior orbital gyri from the anterior short letter U, intersected by the posteromedial limb of the orbital

M N
insular apex; IP, insular pole; CS, central sulcus of insula. The dotted line indi-
cates the location of the inferior limiting sulcus of insula. I, schematic draw-
ing of the anterolateral aspect of the right insula. 0, accessory gyrus; 1ⴕ, trans-
verse gyrus of Eberstaller; 1, anterior short gyrus; 2, middle short gyrus; 3,
posterior short gyrus; 4, anterior long gyrus; 5, posterior long gyrus; IA,
insular apex. J, schematic drawing depicting a posterosuperomedial view of the
walls of the insula. ANT., anterior; SUP., superior; INS., insular; INF., infe-
rior. K, schematic drawing depicting a posterosuperior view of the walls of the
insula. The anterior wall is in yellow, the superolateral facet is in light blue,
and the inferolateral facet is in red. L, basal view of the right frontal lobe. 1,
anterior orbital gyrus; 2, lateral orbital gyrus; 3, medial orbital gyrus; 4, pos-
terior orbital gyrus; 5, rectus gyrus; 6, pars orbitalis; 7, transverse gyrus; 8,
insular pole. The arrows indicate anterior insular cleft. The arrowheads indi-
cate posteromedial limb of the orbital sulcus. Asterisk, posteromedial orbital clinoid segment); 12, olfactory tract and optic nerve. The arrowheads indicate
lobule, just anterior to the lateral olfactory stria and lateral to the olfactory sul- the extent of the M1 segment of the MCA from the carotid bifurcation to the
cus. M, frontal view. A coronal cut has been made at the level of the bifurca- limen insulae. N, basal view of the right hemisphere. A coronal section, fol-
tion of the internal carotid artery (anterior perforated substance). 1, insula; 2, lowed by an axial section, has been performed at the level of the anterior per-
internal capsule; 3, thalamus; 4, claustrum, external and extreme capsules; 5, forated substance. 1, frontal horn; 2, accessory gyrus of the insula; 3, lentiform
lentiform nucleus; 6, thalamostriate vein, column of the fornix, and anterior nucleus and the internal capsule; 4, head of the caudate nucleus; 5, genu of the
commissure; 7, hypothalamus; 8, lateral lenticulostriate arteries and insular MCA; 6, insular pole; 7, anterior perforated substance; 8, amygdala; 9, head
pole; 9, lamina terminalis and anterior cerebral artery (A1 segment); 10, mid- of the hippocampus.
dle cerebral artery (MCA) (M2 segment); 11, internal carotid artery (supra-
sulcus (Fig. 6L). Figure 6L clearly shows that the transverse portion of the uncus that corresponds to the medial nucleus of
gyrus extends more medially to the insular pole. the amygdala is located immediately below the optic tract. The
The anterior perforated substance resembles a convex cavity optic tract is located anteriorly to the upper portion of the crus
extending upward at the posterior end of the basal surface of cerebri. The inferior choroidal point is located laterally to the
the frontal lobe. The roof of the anterior perforated substance is crus cerebri and below the optic tract.
located at a higher level than the olfactory striae and the olfac- At the level of posteromedial orbital lobule, the gray matter
tory tract. The medial part of the anterior perforated substance of the orbital gyri is still separated from the anteroinferior por-
is located more superior than its lateral part. tion of the basal ganglia (the head of the caudate nucleus and
The anterior perforated substance is limited anteromedially the lentiform nucleus) by a band of white matter, and the head
by the posterior edge of the rectus gyrus and by the medial of the caudate nucleus is projected directly above the posterior
olfactory striae. Anterolaterally it is limited by the lateral olfac- half of the olfactory sulcus and tract.
tory striae, the medial end of the transverse gyrus, and the pos- At the level of the roof of the anterior perforated substance,
teromedial orbital lobule. It is limited posterolaterally by the the lentiform nucleus comes almost directly to the cisternal
upper portion of the anteromedial surface of the uncus and surface, and the globus pallidus is projected directly above the
posteromedially by the optic tract (Fig. 6B). The most superior bifurcation of the internal carotid artery (Fig. 6, E, M, and N).

WEN ET AL.
Sylvian Fissure:
Topographic Relationships
A B
Sylvian Fissure versus
Anterior Perforated
Substance versus Basal

Ganglia
The neural structure on the

basal aspect of the cerebrum
that separates the sylvian
fissure from the carotid cis-
tern (sylvian vallecula) is the
limen insulae (Fig. 7A). The
olfactory tract points posteri-
orly toward the anterior per-
forated substance, which is
the roof of the carotid cistern
C
(Fig. 6B).
Pars Triangularis, FIGURE 7. A, frontobasal view of the

Precentral Gyrus, and right hemisphere. The anterior part of the
Supramarginal Gyrus planum polare has been retracted inferi-
versus Insula orly to display the anterior aspect of the
insular pole. 1, anterior orbital gyrus; 2,
The lateral surface of the
medial orbital gyrus; 3, rectus gyrus; 4,
insula is almost evenly cov-
pars triangularis; 5, posterior orbital
ered by these opercula. The gyrus; 6, pars opercularis; 7, anterior
frontal and parietal opercula short gyrus of the insula; 8, anterior per-
cover the upper half of the lat- forated substance. The arrowheads indi-
eral surface, and the temporal cate the limen insulae. B, lateral view of
operculum covers its lower the left cerebral hemisphere. The inferior
half. The posterior ramus and frontal and supramarginal gyri have been
the lateral opercular compart- removed to display the relationship D
ment of the sylvian fissure between the insula and the opercula of the
precentral and postcentral gyri. 1, precen-
divide the insula equidis-
tral gyrus; 2, central sulcus; 3, postcentral
tantly in upper and lower
gyrus; 4, anterior short gyrus of the
halves (Fig. 6, E–G). insula; 5, posterior orbital gyrus and the
When viewed from a lateral anterior insular cleft; 6, central sulcus and
perspective, the anterior zone the anterior long gyrus of the insula; 7,
of the lateral surface of the posterior long gyrus of the insula and the
insula is covered by the pars inferior limiting sulcus of the insula; 8,
triangularis, pars opercularis, insular apex and insular pole; 9, middle
and precentral gyrus on the temporal gyrus. C, lateral view of the left
frontal side and by the cerebral hemisphere. The posterior portion
of the superior temporal gyrus, the upper
planum polare on the tempo-
portion of the middle temporal gyrus, and
ral side. Because of their
the supramarginal gyrus have been
oblique direction (medially to removed. 1, precentral gyrus; 2, corpus
laterally and posteriorly to callosum; 3, postcentral gyrus; 4, septum
anteriorly), the postcentral pellucidum at the level of the frontal horn; 5, upper portion of the atrium; 6, superior temporal gyrus; 7, calcar avis and
gyrus on the parietal side and the glomus of the atrium (choroid plexus); 8, hippocampus; 9, inferior temporal gyrus. D, superolateral view of the right
the Heschl’s gyrus on the cerebral hemisphere. 1, left atrium; 2, left frontal horn; 3, splenium of the corpus callosum; 4, foramen of Monro and cau-
temporal side cover the poste- date nucleus; 5, bulb of the callosum; 6, thalamus; 7, anterior extremity of the anterior limb of internal capsule; 8, calcar
rior zone of the lateral surface avis; 9, lentiform nucleus; 10, anterior insular cleft; 11, collateral trigone; 12, sublenticular portion of the internal capsule.
of the insula and the retroin-
sular region (Fig. 4, C–E).
Therefore, the posterior limit of the anterior zone of the insula the posterior margin of the precentral gyrus. The posterior zone
is projected superficially onto the sylvian fissure approximately at is projected onto the sylvian fissure at approximately the level of

the postcentral gyrus, and the retroinsular region is projected rior, posterior, and inferior portions of the internal capsule
onto the sylvian fissure approximately at the anterior margin of (Figs. 6, E–G, and 7D).
the supramarginal gyrus (Fig. 7B).
The whole AP extent of the insula is therefore projected on Frontobasal Area
the lateral surface of the cerebrum from the horizontal ramus of The main structures located superior to the basal surface of the
the sylvian fissure anteriorly to the anterior margin of the frontal lobe are the frontal horn, corpus callosum, and basal gan-
supramarginal gyrus posteriorly. glia. The beginning of the tip of the frontal horn is located approx-
The pars triangularis of the inferior frontal gyrus covers the imately halfway between the frontal pole and the anterior border
apex of the insula, and the lentiform nucleus is projected super- of the anterior perforated substance, i.e., approximately at the
ficially onto the insula from the second short gyrus to the long level of the horizontal limb of the orbital sulcus. In this area, the
gyrus, before the retroinsular region. rostrum of the corpus callosum separates the frontal horn from the
The precentral gyrus starts in the midline and courses ante- posterior and medial orbital gyri, the olfactory tract, and the rec-
riorly and laterally to reach the sylvian fissure. The operculum tus gyrus (Fig. 8A). At the level of the optic nerves or the anterior
of the precentral gyrus covers the middle third and the ante- border of the anterior perforated substance, the head of the cau-
rior portion of the posterior third of the insula (Fig. 4, D and date nucleus is located immediately above the gray matter over-
E). The genu of the internal capsule is projected over the mid- lying the olfactory tract and is separated from the latter by a thin
dle third of the insula, whereas the pyramidal tract is pro- layer of white matter. At this same level, the lentiform nucleus is
jected over the posterior half of the insula. Because of the located immediately above the posteromedial orbital lobule and
clockwise rotation of the fibers of the precentral gyrus, the above the transverse gyrus of the insula and is separated from the
fibers that are more laterally originated in the convexity, latter by a thicker layer of white matter interposed by the claus-
namely, fibers from the tongue and face, are located more ante- trum (Fig. 8B). At the level of the anterior perforated substance or
riorly at the genu of the internal capsule. Fibers that are orig- at the level of the optic chiasm, the lentiform nucleus comes
inated close to the midline, namely, fibers from the foot, are directly into the cisternal surface (Fig. 8C).
located more posteriorly, at the posterior limb.
MCA: Anatomic Dissections with Angiographic Correlation
Lateral Ventricles versus Frontal, Temporal, The M1 segment of the MCA extends from the carotid bifur-
and Parietal Opercula cation to the limen insulae and can be divided into proximal
The frontal horn can be reached by following the direction of and distal halves. The proximal half is related superiorly to the
the anterior limiting sulcus, the body of the lateral ventricle by anterior perforated substance, posteriorly to the upper portion
following the superior limiting sulcus, and the atrium and the of the anteromedial surface of the uncus, inferiorly to the infe-
temporal horn by following the inferior limiting sulcus of the rior portion of the anteromedial surface of the uncus, and ante-
insula. The temporal horn is projected at the level of the mid- riorly to the stem of the sylvian fissure, the frontotemporal
dle temporal gyrus, the inferior portion of the atrium is pro- arachnoid reflection, and the lesser wing of sphenoid. The dis-
jected at the posterior portion of the superior temporal gyrus tal half of the M1 is related superiorly to the inferior portion of
(infrasylvian), and the upper portion of the atrium is projected the anterior surface of the insula, posteriorly to the inferior
over the supramarginal gyrus (suprasylvian). The anterior por- portion of the insular pole, inferiorly to the anterior portion of
tion of the frontal horn can be reached via the anterior limiting the planum polare, and anteriorly to the stem of the sylvian fis-
sulcus of the insula (Figs. 5C and 7C). sure, frontotemporal arachnoid reflection, and the lesser wing
The projection of the lateral ventricle over the lateral surface of sphenoid (Figs. 6M and 9, A and B).
of the cerebral hemisphere can be estimated by an axial plane The M2, or insular, segment is related to the surfaces of the
that extends from the base of the pars triangularis anteriorly to insula: it begins at the limen insulae, turns around the insular
the inferior portion of the supramarginal gyrus posteriorly (just pole to constitute the genu of the MCA, then sends off branches
above the posterior end of the sylvian fissure), as shown in over the anterior and the lateral surfaces of the insula (they
Fig. 6B. course in the anterior, superolateral, and inferolateral insular
clefts). When those branches reach the limiting sulci of the
Basal Ganglia and Thalamus versus Insula insula (anterior, superior, and inferior), they become the M3
The insula is the external covering of the central core of segment (Fig. 9C).
the hemisphere, and the lentiform nucleus can be analogous The M3, or opercular, segment of the MCA starts at the ante-
to a short shield that stands between the insula and the rior, superior, or inferior limiting sulcus of the insula. It then
internal capsule. The anterior extremity of the lentiform courses between the orbital operculum and the planum polare
nucleus starts at the level of the second short gyrus of the on the basal surface or between the frontal and parietal oper-
insula and ends before the posterior long gyrus of the insula. cula above and the temporal operculum below on the lateral
When viewed from the insular side, the lentiform nucleus surface to exit the sylvian fissure (the sylvian fissure stem on
covers the central portion of the internal capsule; however, the basal surface and the 3 rami of the sylvian fissure on the lat-
the peripheral part around the “short shield” is not covered. eral surface). Once they exit the sylvian fissure, they become
The peripheral part is composed of the most anterior, supe- the M4, or cortical, segment (Fig. 9D).

WEN ET AL.
Clinical Application of Anatomic Information

A and Discussion
One of the most difficult tasks when studying the anatomy
of the central nervous system is to distinguish what informa-
tion is relevant because what is important to neurosurgeons

might not be relevant to anatomists and vice versa. In the
authors’ experience, most of the time, this distinction can only

be made when we are actively examining radiological images,
planning surgical strategies, and performing surgeries. The
following are some of the clinical applications of sylvian fis-
sure region anatomy.
Angiography
The neural and vascular structures along the trajectory of
the M1 segment can be identified easily. At the limen insulae,
the M1 becomes M2 and turns around the pole of the insula.
B This turn is easily recognized angiographically. The insula can
be identified as the neural structure located immediately

medial to the M2 segment of the MCA. The several loops
formed by the M2 when it reaches the superior circular sulcus
of the insula can also be identified angiographically. These sev-
eral loops approximately indicate the location of the superior
circular sulcus of insula. The first loop of the M2 is usually
located more medially on angiography than the subsequent
loops because the first loop usually is located in the anterior
insular cleft. The last loop of the M3 segment that loops over
the temporal operculum and exits the sylvian fissure consti-
tutes an important angiographic landmark: the sylvian point or
the M point (21, 24). The sylvian point is usually located on the
most medial aspect of the Heschl’s gyrus or even on the most
medial aspect of the planum temporale. Besides being the last
loop, the sylvian point is usually the most medial loop on the
C temporal side. This is explained by the anatomy of the retroin-
sular region because both the Heschl’s gyrus and the planum
temporale enclose the insula posteriorly and medially toward
the atrium of the lateral ventricle and because the retroinsular
region is located more medially than the anterior portion of the
insula (Figs. 2E and 9, B and D).
The morphology of the other M3 loops on the temporal oper-
culum can also be explained by the anatomy of the temporal
operculum: the M3 segment that courses over the planum tem-
porale presents a straight morphology because it courses
between the opercula of the supramarginal and postcentral
gyri above and the planum temporale and the Heschl’s gyrus
below. All these present flat surfaces, allowing no space for
FIGURE 8. A, a coronal cut at the level of the planum sphenoidale, just ante- olfactory tract. B, a coronal cut was performed at a level between the cuts
rior to the head of the caudate nucleus has been made. 1, head of the caudate shown in Figs. 8A and 6C. 1, transverse gyrus of Eberstaller; 2, posterome-
nucleus; 2, genu of the corpus callosum; 3, rostrum of the corpus callosum; dial orbital lobule. C, coronal cut performed at the level of the optic chiasm (at
4, inferior continuation of the cingulate gyrus; 5, inferior continuation of the the anterior perforated substance). 1, caudate nucleus; 2, thalamus, choroidal
medial frontal gyrus; 6, lateral orbital gyrus; 7, posterior orbital gyrus; 8, fissure, and thalamostriate vein; 3, internal capsule, transition between the
medial orbital gyrus; 9, rectus gyrus and the olfactory tract. The superior ros- anterior limb and the genu; 4, foramen of Monro and column of fornix; 5,
tral sulcus is located between the 4 and 5, and the inferior rostral sulcus is putamen; 6, globus pallidus; 7, lamina terminalis and hypothalamus; 8, optic
located between the 5 and 9. The posteromedial limb of the orbital sulcus is chiasm. Asterisk, anterior commissure.
located between the 7 and 8. The olfactory sulcus is located superiorly to the

A B
C D
FIGURE 9. A, basal view of the cerebrum. 1, anterior orbital gyrus; 2, olfactory gual gyrus and calcarine artery; 3, calcar avis, atrium, and posterior transverse
tract; 3, lateral orbital gyrus; 4, medial orbital gyrus; 5, rectus gyrus; 6, insula; temporal gyrus; 4, vein of Galen; 5, glomus of atrium and sylvian point; 6, mid-
7, anterior perforated substance; 8, insular pole; 9, amygdala; 10, carotid bifur- dle transverse temporal gyrus; 7, tentorial edge and trochlear nerve; 8, P2P seg-
cation, oculomotor nerve, and the optic tract; 11, head of the hippocampus. The ment of the posterior cerebral artery, parahippocampal gyrus, and fornix; 9,
arrowheads indicate the extent of M1 segment. B, superior view. 1, orbit; 2, genu superior limiting sulcus of the insula; 10, inferior choroidal point (entry point
of the MCA; 3, planum polare; 4, olfactory tract and optic nerve; 5, anterior cere- of the anterior choroidal artery in the temporal horn); 11, Heschl’s gyrus; 12,
bral artery; 6, insular pole; 7, anteromedial surface of the uncus; 8, posterior lentiform nucleus; 13, crus cerebri; 14, apex and the posteromedial surface of the
communicating artery; 9, head of the hippocampus; 10, posteromedial surface of uncus and the anterior choroidal artery; 15, P1 segment of the posterior cerebral
the uncus, anterior choroidal artery, and P2A segment of the posterior cerebral artery and the posterior communicating artery; 16, head of the hippocampus; 17,
artery; 11, medial end of the Heschl’s gyrus and the sylvian point; 12, midbrain; supraclinoid carotid artery and anteromedial surface of the uncus; 18, limen
13, atrium. M1, M2, M3, M4, segments of the MCA. C, lateral view of the left insulae and insular pole; 19, planum polare; 20, deep middle cerebral vein; 21,
insula and M2 segment of the MCA. 1, corpus callosum; 2, superior limiting anterior cerebral artery and optic nerve; 22, lesser wing of the sphenoid; 23, genu
sulcus of insula; 3, anterior limiting sulcus of insula; 4, inferior limiting sulcus of the MCA; M1, sphenoid segment of the MCA; M2, insular segment of the
of the insula; 5, straight sinus; 6, orbit; 7, tentorial edge and middle fossa. D, MCA; M3, opercular segment of the MCA; M4, cortical segment of the MCA;
anteroposterior (AP) view as in angiography. 1, parieto-occipital artery; 2, lin- IE, insular edge.
curves. Only those M3 segments that course over the temporal morphology because, anatomically, the planum polare is a
opercula ahead of the Heschl’s gyrus present a rather curved depression and provides space for curves.

WEN ET AL.
Heschl’s gyrus points toward

A B the atrium of the lateral ven-
tricle, and the pulvinar of the
thalamus, which is the ante-
rior wall of the atrium.

The central core of the cere-
bral hemisphere, composed

of the basal ganglia, thala-
mus, internal, external and
extreme capsules, and claus-
trum, can be identified
promptly in an AP view of
carotid angiography: it is
located in the rectangle lim-
ited anteriorly by the A1, M1,
and genu of the MCA, medi-
ally by the distal anterior
C cerebral artery (A2–A5 seg-

ments), laterally by the M2
segment, and posteriorly by a
transverse line drawn from
the sylvian or M point.
FIGURE 10. A, carotid angiography, AP view. The The location of any angio-
small red arrowheads indicate the M2 segment of graphically visible vascular
the MCA. The green arrowheads indicate the M3 lesion in the sylvian fissure of
segment of the MCA over the planum polare. The
the lateral surface of the cere-
green arrows indicate the M3 segment of the MCA
brum also can be roughly esti-
over the planum temporale. The blue arrowheads
indicate the M4 segment of the MCA over the pari- mated: the first loop of the M2
etal area. The blue arrows indicate the location of usually indicates the location
the intraparietal sulcus. The purple arrow indicates of the anterior limiting sulcus
the superior limiting sulcus of insula. The large of the insula (the anterior limit
red arrowhead indicates the projection of the loca- of the insula), the sylvian
tion of the tip of the pars triangularis, just distal to point indicates approximately
the genu of the MCA. B, medial view of the right the posterior limit of the
cerebral hemisphere with the crus cerebri removed insula, and the first M3 seg-
to display the trajectory of the M1 segment in this projection. 1, thalamus; 2, M1 segment of the MCA; 3, uncus and
ment that displays a straight
the inferior choroidal point; 4, anterior cerebral artery; 5, anterior choroidal artery; 6, P2A segment of posterior cere-
morphology indicates the
bral artery; 7, posterior communicating artery; 8, P1 segment of posterior cerebral artery; 9, supraclinoid carotid
artery. C, carotid angiography, lateral view. The red arrows indicate anterior limiting sulcus. Blue arrows indicate location of the Heschl’s gyrus
superior limiting sulcus. The green arrows indicate inferior limiting sulcus. M, sylvian point. or the planum temporale
(Figs. 9D and 10A).
In an AP view of carotid
Looking at the AP view of the carotid angiography, we can angiography, the temporal lobe is projected as follows: the
recognize the neural structures located along the trajectory of planum temporale, Heschl’s gyrus, and planum polare are all
the M1 and M2. The insula is located medially to the M2, and projected to the outer periphery of the arch formed by the dis-
the frontal, parietal, and temporal opercula are projected later- tal half of the M1, the genu, and the whole extent of the M2 up
ally to M2, between the M2 and M4 segments. The curvature to the sylvian point. The anterior segment of the uncus is pro-
and morphology of the M3 branches of the frontal and parietal jected at the outer periphery and behind the proximal segment
opercula determine the location of that particular M3 branch. In of M1. The apex of the uncus is projected behind the supracli-
the anterior frontal operculum, they loop shallowly, loop noid carotid artery. The posterior segment of the uncus, the
deeply in the central region, and then exit straight with a long parahippocampal gyrus, the temporal horn, and the hippocam-
course in the postcentral region. In the posterior parietal region, pus are all projected inside the square formed by the M1, the
they exit straight with a short course (19). A1 anteriorly, the distal anterior cerebral artery medially, the
The sylvian point can provide the location of the following M2 and the sylvian point laterally, and an imaginary line traced
structures: the medial end of the Heschl’s gyrus and conse- horizontally from the sylvian point toward the midline. The
quently the retroinsular space, the posterior extremity of the medial limit of the parahippocampal gyrus is projected approx-
posterior limb of the internal capsule, the atrium because the imately halfway between the distal anterior cerebral artery and

the M2 (Figs. 9D and 10A). In an AP view of vertebral angiog- ment of the uncus is projected at the level of the carotid artery,
raphy, the medial limit of the temporal lobe is the posterior the apex of the uncus is projected behind the carotid artery, and
cerebral artery (P2A, P2P, and P3 segments). the temporal horn starts behind the carotid artery and is pro-
Both frontal and occipital poles can be superimposed on jected at the level of the middle temporal gyrus (Fig. 9B). In a
MCA branches in an AP view. However, as shown in Figure lateral view of the vertebral angiography, the apex and the
4G, the largest transverse diameter of a normal brain (the anterior segments of the uncus are projected anteriorly to the
suprasylvian lateral convexity) is located at the level of the basilar artery, and the posterior segment of the uncus is pro-
postcentral gyrus. Therefore, the most laterally located vessels jected over the basilar tip and the P2A segment of the posterior
over the lateral convexity in an AP view are most likely run- cerebral artery. The inferior temporal gyrus is also the lowest
ning on the postcentral gyrus. Both the frontal and occipital part of the temporal lobe in the lateral view. Because of the
poles present a smaller transverse diameter. Therefore, vessels obliquity of the tentorium cerebelli, the medial part being
running over those poles are usually not the most laterally higher than its lateral part, the medial edge of the parahip-
located ones in an AP view. pocampal gyrus is located higher than the inferior temporal
The same consideration can also be applied to the middle gyrus, approximately at the level of the inferior temporal sul-
temporal gyrus at the level of the postcentral gyrus. The largest cus or middle temporal gyrus, when viewed laterally.
transverse diameter of the brain on the infrasylvian convexity In a standard AP view of a person with a normal cranial con-
is located at the level of the superior or middle temporal gyrus figuration, the largest transverse diameter of the cerebrum is
at the same coronal plane as the postcentral gyrus. located at the level of the postcentral gyrus (suprasylvian) and
In the lateral view of the carotid angiography, it is difficult to the middle temporal gyrus (infrasylvian). Therefore, the most
visualize the trajectory of the M1 segment because the view laterally located vessels in an AP view are most likely related to
angle is the same as the main axis of the M1 (Fig. 10B) and those gyri. The vessels that course on the frontal lobe or occip-
because of the superimposition of the vessels. Also in the lateral ital lobe will be projected more medially than the vessels cours-
view, the loops of the MCA, mainly composed of the M2 and ing on the postcentral and middle temporal gyri (Fig. 4G).
M3 segments over the insula and adjacent frontal, parietal, and There is controversy about the definition of the M1 segment
temporal opercula, form the sylvian triangle (16, 21). of MCA. Yaşargil (31) and Taveras and Pile-Spellman (21) have
The sylvian triangle resembles a right triangle with the right defined M1 as extending from the carotid bifurcation to the
angle represented by the junction between the anterior and limen insulae, and according to Yaşargil (31), the true bifurca-
superior limiting sulci of the insula and the hypotenuse repre- tion of the proximal M1 always occurs at the highest point of
sented by the inferior limiting sulcus of the insula (Figs. 9C and the limen insulae. Gibo et al. (5) and Rhoton (13) have defined
10C). This triangle basically displays the shape of the insula; the extent of M1 from the carotid bifurcation to the genu of
this, in turn, approximately indicates the location of the “cen- MCA. The word limen comes from a Latin root meaning
tral core” of the hemisphere. The structures of the central core threshold; the limen was named to describe the medial border
will be projected inside the triangle except for the caudate of the insula that separates the sylvian vallecula from the syl-
nucleus; the head and the body of the caudate nucleus are vian fissure cistern (8, 30). Earlier publications reported the syl-
located above the lateral projection of the superior limiting sul- vian vallecula cistern as the hilum of the brain and that the
cus of the insula (Fig. 6E). bifurcation of the internal carotid artery, and the first portions
The lateral ventricle is projected outside the sylvian triangle, of the anterior and middle cerebral arteries lie within it (30).
the frontal horn is projected ahead and above the anterior lim- This is actually a precise description of the carotid cistern.
iting sulcus, the body of the lateral ventricle is projected above For Krayenbuhl et al. (7), the practical meaning of limen
the superior limiting sulcus of the insula, the atrium is pro- insulae is the entrance to the insula. If one defines the extent of
jected behind the junction between the superior and the inferior M1 from the carotid bifurcation to the limen insulae, it means
limiting sulcus of the insula, and the temporal horn is pro- that the entire M1 segment courses within the carotid cistern. If
jected below the inferior limiting sulcus of the insula. the genu of the MCA is defined as the distal end of M1, most of
As mentioned previously, in normal conditions, the opercu- M1 still courses within the carotid cistern, and a small distal
lum of the precentral gyrus covers the middle third and the part of it courses within the sylvian fissure.
anterior portion of the posterior third of the insula. The anterior The variations of the trajectory of the M1 segment have been
and posterior limits of the insula can be seen in angiography by extensively studied by Krayenbuhl et al. (7) and Taveras and
identifying, respectively, the first loop of the sylvian triangle Pile-Spellman (21). Regardless the definition of the M1 seg-
and the sylvian point. Thus, it is theoretically possible to deter- ment, surgeons should be able to identify it on angiography,
mine the middle third between those 2 landmarks and to deter- recognize its topographical relationships, and identify it intra-
mine the location of the precentral gyrus region by analyzing operatively.
the morphology of the vascular loops. The morphology of the M1 segment, whether straight or
In the lateral view of carotid angiography, the temporal lobe curved, is highly dependent not only on the length of the M1
is projected as follows: the anterior portion of the planum itself, but also the height of the carotid bifurcation. The M1
polare and the genu of the MCA are projected anteriorly to the segment turns around the insular pole to constitute the genu
projection of the siphon of the carotid artery, the anterior seg- regardless of M1’s morphology or curvature. Therefore, if the

WEN ET AL.
A B
C
FIGURE 11. A, intraoperative photograph displaying cerebral exposure after
a standard right pterional craniotomy. The tip of the suction tube has
retracted the pars triangularis medially. 1, posterior orbital gyrus; 2, lateral
orbital gyrus (pars orbitalis). The blue arrowheads indicate frontotemporal
arachnoid reflection on the basal surface. The black arrowheads indicate fron-
totemporal arachnoid reflection on the lateral surface. B, continuation of A.
The frontotemporal arachnoid membrane has been split to display the anterior
opercular compartment of the sylvian fissure on the basal surface. 1, lesser
wing of the sphenoid; 2, planum polare; 3, insular apex. The posterior orbital
gyrus is retracted medially by the tip of the suction tube. The black arrow-
heads indicate the frontotemporal arachnoid membrane. The blue arrow indi-
cates the beginning of the anterior insular cleft. C, continuation of B. The
frontotemporal arachnoid membrane and the anterior opercular compartment
have been further split to display the anterior insular compartment. The M1
segment of the MCA courses in the lower part of the anterior operculoinsu-
lar compartment (sphenoidal compartment). The blue arrow indicates the
anterior insular cleft.
carotid bifurcation is low, the M1 tends to be straight; if the orbitalis, which occupies both lateral and basal surfaces of the
carotid bifurcation if high, the M1 tends to be curved; and if the cerebrum. On the lateral surface, the tip of the pars triangularis
carotid bifurcation is high and the M1 is elongated, the M1 is located approximately 2 cm from the sharp transition
tends to make a double curve. between the basal and lateral surfaces (Fig. 12B).
Knowing the location of the tip of the pars triangularis, the
Pterional Transsylvian Approach approximate location of the frontal horn can be determined as
In a standard pterional approach, the usual cerebral exposure well because it can be reached at the level of the base of the
can be seen (Fig. 11A). pars triangularis. This information can be helpful when the
It is possible to see the frontotemporal arachnoid reflection frontal horn has to be punctured.
that covers the superficial part of the sylvian fissure. The pars Knowing the location of the pars triangularis also allows us
triangularis can usually be determined because it is the only to know the approximate location of the anterior limit of the
part of the frontal operculum that habitually is retracted central core because the location of the pars triangularis leads
upward; this, in combination with the medial deviation of the automatically to the horizontal ramus of the sylvian fissure
planum polare, leaves a larger space for arachnoidal opening. that continues medially with the anterior limiting sulcus of the
However, when the pars triangularis cannot be promptly iden- insula, and this will ultimately determine the anterior limit of
tified, an alternative is to check the sharp transition between the central core or will lead us to the frontal horn.
the orbital and the lateral surfaces of the frontal lobe because It is usually very difficult to identify a specific sulcus on
the edge of this transition can easily be seen on the pars the orbital surface of the frontal lobe; only the medial limit

A B
FIGURE 12. A, lateral view of C D

the left hemisphere. The pars
orbitalis has been retracted ante-
rior and superiorly. 1, precentral
gyrus; 2, postcentral gyrus; 3,
pars triangularis, anterior hori-
zontal, and anterior ascending
rami of the sylvian fissure; 4,
orbitalis; 5, pars opercularis; 6,
posterior orbital gyrus and the
anterior insular cleft; 7, lesser
wing of the sphenoid. Asterisk,
insular apex. M2, insular seg-
ment of the MCA that has just
turned around the insular pole
(just distal to the genu of the
MCA). B, same specimen in A
in surgical position (left pteri-
onal exposure). The spatula on the left side is retracting the planum tempo- M2, insular segment of the MCA that has just turned around the insular pole
rale, and the spatula on the right side is retracting the posterior portion of the (just distal to the genu of the MCA). Asterisk, insular apex. The arrowheads
pars orbitalis. 1, lesser wing of sphenoid; 2, superior temporal gyrus; 3, pars indicate the sharp transition between the basal and lateral surfaces of the cere-
orbitalis; 4, middle temporal gyrus; 5, posterior orbital gyrus; 6, anterior brum. C, AP view of a right carotid angiography. Note the laterally deviated
insular cleft and anterior short gyrus of the insula; 7, posterior long gyrus supraclinoid carotid artery, the initial upward course followed by a downward
and the inferior limiting sulcus of the insula; 8, pars triangularis; 9, precen- curve of the M1, and then a rather horizontal course to turn around the insu-
tral gyrus; 10, pars opercularis; 11, Heschl’s gyrus; 12, postcentral gyrus; lar pole. D, the expected intraoperative course of the M1 shown in C.
of the orbital gyri can be easily identified by the olfactory The compartments of the sylvian fissure on the basal surface
tract. However, the frontotemporal arachnoid reflection can of the brain have been defined as superficial (sylvian fissure
help in identifying not only the posterior portion of the lat- stem) and deep (sphenoidal compartment) (5, 13). Although
eral, posterior, and medial orbital gyri, but also the anterior this is a classic definition, it apparently does not accurately
half of the planum polare in a transsylvian approach because depict the anatomy of the sylvian fissure in that region. It is
this arachnoidal reflection is attached to those structures clear that there is an opercular compartment composed of oper-
(Figs. 5A and 11A). culum of the planum polare and the opposing operculum of
When it is necessary to release cerebrospinal fluid from the the lateral and posterior orbital gyri (Fig. 11, B and C). The
carotid cistern to “relax” the brain before splitting the sylvian term sphenoidal compartment might suggest the close rela-
fissure, the identification of the posterior portion of the olfac- tionship of the lesser wing of the sphenoid to the deep com-
tory tract can guide the surgeon to the carotid cistern (Fig. 5B). partment of the sylvian fissure or might depict the relation-
After opening the superficial part of the sylvian fissure, the ship of the M1 segment, also called the sphenoidal or
intermediate, or opercular, compartment can be exposed (Fig. horizontal segment, to the lesser wing of the sphenoid bone.
11, B and C). However, the sphenoidal compartment actually arises in the

WEN ET AL.
region of the limen insulae at the lateral margin of the anterior An MCA aneurysm that is located at or distally to its genu is
perforated substance as a narrow space posterior to the sphe- more superficial and can usually be promptly located intraop-
noid ridge between the frontal and temporal lobes. It commu- eratively. As mentioned previously, the pars triangularis covers
nicates medially with the carotid cistern or sylvian vallecula. the apex of the insula that is located just posterior to the pole
One may automatically associate the term sphenoidal com- of the insula. Therefore, when the surgeon splits the sylvian fis-
partment with the term sphenoidal segment, but they represent sure at the level of the pars triangularis, she or he will expose
different structures. The sphenoidal compartment is restricted the portion of the MCA that has just turned around the pole of
to the region anterior to the insular pole, and the sphenoidal the insula, that is, just distal to the genu of the MCA (Figs. 10A
segment describes the trajectory of M1 behind the lesser wing and 12, A and B). If the aneurysm is located soon after the genu
of the sphenoid bone, medial to the insular pole, within the of MCA, it will be promptly identified.
carotid cistern. If the aneurysm is located before the genu of the MCA, it can
The deep compartment of the sylvian fissure on the basal be located in the proximal half, in the distal half, or between the
surface encompasses the sphenoidal compartment and extends halves of the M1 segment. As mentioned previously, the adja-
into the anterior insular cleft, a space between the posterior cent neural structures are different in those situations.
surface of the lateral and posterior orbital gyri and the anterior The predominant direction of the dome of the aneurysm indi-
surface of the insula. cates the surrounding structures to which the dome of the
Because of its relationship to the anterior surface of the aneurysm might be attached. Retraction on those structures is to
insula, in this study, we called this compartment the anterior be avoided in the beginning of the dissection of the sylvian fissure.
insular compartment and its opercular mate the anterior oper- An MCA aneurysm that points laterally, parallel to M1 on an
culoinsular compartment. AP view in angiography, means that its dome is directed along
In this article, we propose the introduction of the concept of the sylvian fissure, usually parallel to the course of the M1 seg-
the anterior operculoinsular compartment and the lateral oper- ment, and it is pointing toward the surgeon intraoperatively
culoinsular compartment to describe the deep part of the syl- during the pterional approach.
vian fissure on the basal and lateral surfaces, respectively, of the It is very important to know beforehand the course of the M1
cerebral hemisphere. Because the sylvian fissure is formed by segment, as demonstrated by Yaşargil et al. (33), not only for
the infolding of the frontal, parietal, and temporal opercula intraoperative orientation, but also for the purpose of proximal
over the anterior and lateral surfaces of the insula, we believe control.
that the term anterior operculoinsular more clearly delivers the The course and the shape of the M1 segment, as well as the
information about the anatomy of that region. The classically height of its origin from the supraclinoid carotid artery, can
used term sphenoidal compartment does not describe the vary considerably (21). However, the MCA always turns
entire anatomic situation over the anterior surface of the insula around the pole of the insula to constitute its genu to reach the
well. Rather, it describes only the inferior portion of the anterior lateral surface of the insula, regardless the variable course of its
insular compartment where the M1 courses. M1 segment.
When the M1 segment curves inferiorly on angiography, it will
MCA Aneurysm Surgery be curving toward the temporal lobe. When the M1 segment
As in any other aneurysm surgery, in MCA aneurysm sur- curves superiorly on angiography, it will curve toward the ante-
gery, it is very important to evaluate preoperative angiography rior perforated substance or toward the anterior surface of the
to establish the surgical strategy and its application in surgery. insula. The approximate intraoperative course of the M1 segment
Important information can be obtained by evaluating preop- can be displayed when we turn the standard AP view angiogra-
erative angiography, including the exact location of the phy upside down (Fig. 12, C and D). In some cases, there is no
aneurysm and the direction of its dome, the neural structures need to expose the entire M1 segment to find the aneurysm or
adjacent to the aneurysm, the morphology (curvatures) of the even to find a portion of the M1 segment for proximal control.
M1 segment, and the early identification of the parent artery for The next step is to transport all the information obtained
proximal control. from the angiography to the surgery, and the surgeon’s next
The location and the direction of the dome of the aneurysm questions are the following:
and the morphology of the M1 segment can be evaluated by 1) Toward what direction should I proceed with dissection in
analyzing the following questions: the sylvian fissure?
1) Is this aneurysm located before, at, or after the genu of the 2) Where can I or can I not apply retraction to avoid early rup-
MCA? ture of the aneurysm?
2) If the aneurysm is located before the genu of the MCA, is it 3) Where do I expect to find intraoperatively the aneurysm and
in the proximal half, in the distal half, or midway between the M1 segment for proximal control?
the two halves of the M1 segment? After the appropriate positioning and standard pterional
3) Is the dome of the aneurysm directed predominantly for- craniotomy, the cerebrum is exposed. First, we have followed
ward, backward, upward, downward, medially, or laterally? routinely the olfactory tract posteriorly to locate the carotid
4) What is the predominant course of the M1 segment? Is it cistern and released cerebrospinal fluid from it to relax the
straight or curving upward, downward, forward, or backward? brain. After having opened the carotid cistern, the carotid

artery is identified. The sylvian fissure is then split, starting at Because the dome of the aneurysm is directed inferiorly and
the level of the pars triangularis. anteriorly on angiography, it is expected to be directed anteri-
As the pars triangularis is projected over the apex of the orly and superiorly in the surgery (33), and the dome is
insula, as soon as we split the sylvian fissure at that level, we expected to be in close relation to the anterior half of the planum
will encounter the M2 segment that has just turned around the polare, sylvian fissure stem, frontotemporal arachnoid reflec-
insular pole and the apex of the insula (Fig. 12B). tion, and lesser wing of sphenoid. Its dome is expected to be
The anterior pole of the insula and, consequently, the limen superficially located when viewed intraoperatively. The drilling
insulae are located more medially and posteriorly than the tip of the lesser wing and the opening of the dura mater must be
of the pars triangularis. The aneurysms that are located soon performed with caution (Fig. 13, D and E). After originating the
after the genu of the MCA are located at the level of the pars tri- aneurysm, the MCA courses almost straight to curve around the
angularis, and the aneurysms that are located at the level of the insular pole to constitute the genu of the MCA. In this case, the
insula pole are projected more medially and posteriorly in rela- sylvian fissure was split proximal to the pars triangularis
tion to the tip of the pars triangularis. Those aneurysms arising because of the location of the aneurysm (Fig. 13F).
before the insula pole are projected even more medially and Case 2. The M1 segment is almost straight and horizontal.
posteriorly in relation to the pars triangularis (Fig. 6D). At the distal half of M1, before the insular pole, it bifurcates
If the aneurysm is located immediately distal to the genu of and gives rise to an aneurysm that points slightly superiorly
the MCA, it can be found quickly when the sylvian fissure is and laterally. It is difficult to evaluate the lateral view on an
split at the level of the pars triangularis. If the aneurysm is angiogram because of the superimposition of the vessels, but
located more distally, its location can be estimated by looking in this case, the aneurysm’s location was confirmed by
at the distance of the aneurysm to the genu of the MCA and angiography–computed tomographic (CT) scan. In the distal
to the sylvian point on the AP view angiography. If the half of M1, the aneurysm is related superiorly to the anterior
aneurysm is located midway between the sylvian point and surface of the insula. Slight lateral projection of the aneurysm
the genu of MCA, it will probably be located at the level of the indicates that it is mostly located inside the sylvian fissure
precentral gyrus, or it can be located by looking at the lateral (Fig. 14, A–C).
view angiography by locating the aneurysm inside the sylvian When the sylvian fissure is split at the pars triangularis, the
triangle. The anterior limit of the sylvian triangle is located at aneurysm is expected to be located proximally to the insular
the level of the anterior limiting sulcus that continues super- pole, with most of the aneurysm located inside the anterior
ficially as the horizontal ramus of the sylvian fissure, and the insular compartment of the sylvian fissure (Fig. 14, D and E).
sylvian point is projected at the anterior margin of the supra- Case 3. The M1 segment is initially directed superiorly and
marginal gyrus. If it is midway between the two, it probably laterally. Midway between its proximal and distal halves, M1
is located at the level of the precentral gyrus. If it is located at gives rise to an aneurysm that is pointing superiorly and
the level of the anterior zone of the insula, it will be related to slightly anteriorly. After giving rise to the aneurysm, M1 con-
the pars opercularis or triangularis. If it is related to the pos- tinues downward toward the insular pole (Fig. 15, A–C).
terior zone of the insula, it will be related to the pre- or post- The initial upward curvature of M1 indicates that it is curv-
central gyrus. Therefore, the intraoperative location of a dis- ing toward the anterior perforated substance. Midway between
tal MCA aneurysm can be calculated between the pars the proximal and distal halves of the M1 is the transition
triangularis and the supramarginal gyrus, and the intraoper- between the anterior perforated substance and the medial limit
ative identification of the operculum of the precentral gyrus of the insular pole (Fig. 15, D–F).
can be a helpful landmark. In these 3 illustrative cases, the first step in the surgery was
However, in most cases of MCA aneurysms, the aneurysm is to open the carotid cistern to relax the brain and to either
located at or before the pole of the insula, and its intraoperative expose or estimate the location of the carotid bifurcation. The
location can be easily estimated by looking at the distance extent of the MCA from the carotid bifurcation to the genu of
between the bifurcation of the internal carotid artery and the MCA, as shown on angiography, is therefore estimated intraop-
genu of the MCA. The clinical application of the anatomic eratively from the carotid bifurcation to the pars triangularis,
information can be illustrated in the following cases. and the location of the aneurysm is determined according to
Case 1. After the carotid bifurcation, the M1 segment curves the angiography. Depending on the location of the aneurysm
downward and gives rise to the aneurysm that is directed infe- and the direction of its dome, it will be related to different sur-
riorly and anteriorly (Fig. 13, A and B). The aneurysm is located rounding neural structures. Knowing the location of the
before the genu of the MCA, roughly midway between the aneurysm and the direction of its dome beforehand, the sur-
carotid bifurcation and the genu of the MCA. Therefore, it is geon can quickly find the aneurysm, thus reducing the risk of
more medially and posteriorly located than the genu of the its premature rupture because of inadequate brain retraction.
MCA. It is important to keep in mind that opening the sylvian Case 4. A 31-year-old woman had undergone previous sur-
fissure at the level of the pars triangularis will expose the apex gery for a right MCA aneurysm at another neurosurgical cen-
of the insula, distal to the genu of the MCA. This aneurysm is ter in 2000. She was admitted to the emergency department on
located much more medially (proximal) than the level of the March 23, 2008, with a sudden headache, aphasia, and drowsi-
pars triangularis (Fig. 13C). ness. The CT scan is shown in (Figure 16A). The angiography-

WEN ET AL.
A B C
D E
F
FIGURE 13. A, AP view of a left carotid angiography depicting an MCA
aneurysm pointing downward. B, lateral view of the same angiography shown
in A depicting an MCA aneurysm pointing anteriorly and inferiorly. C, sur-
gical exposure after a left pterional craniotomy followed by the dural opening.
1, pars orbitalis; 2, superior temporal gyrus; 3, pars triangularis. D, intraop-
erative photograph. The sylvian fissure was split proximal to the pars orbitalis
to expose the aneurysm. 1, superficial sylvian veins; 2, supraclinoid carotid
artery; 3, optic nerve and anterior cerebral artery; 4, M1 proximal to the
aneurysm; 5, MCA distal to the aneurysm; 6, pars orbitalis; 7, pars triangu-
laris. The olfactory tract is located beneath the tip of the bipolar forceps. E, the
aneurysm shown in D was clipped and the dome opened and cut (at the tip of
the suction tube). 1, temporal branch of the MCA and the planum polare; 2,
carotid artery; 3, pars orbitalis. F, overall view of the surgical exposure after
aneurysm clipping. Note the location of the clip (which indicates the location
of the aneurysm) and the location of the pars triangularis (which indicates
approximately the location of the insular apex, just distal to the insular pole
and to the genu of the MCA). 1, pars orbitalis; 2, pars triangularis.

A B C
D E
FIGURE 14. A, AP view of a left carotid angiography depicting an MCA rional craniotomy and dural opening. Asterisk, pars triangularis. E, the syl-
aneurysm arising proximal to the genu of the MCA, in the distal half of the vian fissure was split just proximal to the tip of the pars triangularis (arrow).
M1 and pointing superiorly in this projection. B, lateral projection of the Note the distance between the aneurysm and the tip of the pars triangularis
same carotid angiography shown in A. Because of the superimposition of the (arrow). The carotid bifurcation is located at the level of the tip of the spatula.
vessels, it is difficult to visualize the aneurysm. C, Angiography-CT depict- 1, supraclinoid carotid artery.
ing the aneurysm (arrow) shown in A. D, surgical exposure after a left pte-
CT scan showed a left distal MCA aneurysm (Fig. 16, B and C). MCA and the sylvian point. The lateral view showed that the
Another hemorrhage was present on the morning of the sur- aneurysm was arising from an M2 segment that was coursing
gery, March 24, and the patient had hemiparesia (Grade 3 close to the hypotenuse of the sylvian triangle, close to the infe-
strength). Figure 16D shows the brain after an extended pteri- rior limiting sulcus of the insula, and that the aneurysm was
onal craniotomy and dural opening. The posterior ramus of related approximately to the transition between the middle and
the sylvian fissure was split, the clot was removed, and the posterior thirds of the lateral surface of the insula.
aneurysm was found at the level of the anterior margin of the The middle third and the anterior part of the posterior third
operculum of the postcentral gyrus (Fig. 16, E and F). of the lateral surface of the insula are usually covered by the
In this case, the most difficult part was determining the intra- operculum of the precentral gyrus. Therefore, preoperative
operative location of the aneurysm by means of angiography- planning entails locating the opercula of the precentral and
CT scan. The AP view showed a distal MCA aneurysm located postcentral gyri along the posterior ramus of the sylvian fis-
slightly distal to the midway point between the genu of the sure; the aneurysm must be located at the transition between

WEN ET AL.
A B C
D E
FIGURE 15. A, AP view of a left carotid angiography depicting an MCA

aneurysm arising approximately midway between the carotid bifurcation and
the genu of the MCA. B, angiography-computed tomographic (CT) scan with
3-dimensional reconstruction showing the same aneurysm. C, angiography-
CT scan with 3-dimensional reconstruction, lateral view. D, exposure after a
left pterional craniotomy and dural opening. asterisk, pars triangularis. E, the
sylvian fissure was split proximal to the pars triangularis (asterisk). Arrow
indicates the carotid bifurcation. The arrowhead indicates the location of the
aneurysm. Note the distance between the pars triangularis and the location
of the aneurysm. F, the aneurysm was clipped, and the frontal branch of the
MCA bifurcation was identified.

A B C
D E
FIGURE 16. A, axial CT scan. There is a

hematoma in the left sylvian fissure. B,
Angiography-CT, coronal view. There is a dis-
tal MCA aneurysm (arrow); it is located
slightly distal to the halfway between the genu
of the MCA and the sylvian point. C,
Angiography-CT, lateral view. The arrowhead
indicates the aneurysm, and the arrow indi-
cates the sylvian point. The aneurysm is
located at the level of the transition between
the middle third to the posterior third of the
insula, close to the inferior limiting sulcus. D, intraoperative photograph depicting the sur- F
face of the brain after an extended left pterional craniotomy and dural opening. The intense
subpial hemorrhage makes the identification of the sulci and gyri difficult. The authors’
interpretation of the case was 1) pars triangularis, 2) pars opercularis, 3) precentral gyrus,
4) postcentral gyrus. Temp., temporal. E, intraoperative photograph showing the aneurysm
arising from a bifurcation of an M2 branch. The arrows indicate the neck of the aneurysm.
The arrowheads indicate the distal branches of the M2 branch. F, intraoperative photo-
graph. The aneurysm was clipped using only the tip of the clip (Because of a lack of vari-
ety of clips available at the time of the surgery), and the clot in the sylvian fissure was
removed. The arrowhead indicates the location of the neck of the aneurysm.
those gyri or at the level of the posterior margin of the precen- intrasylvian clot was removed, and the aneurysm was soon
tral gyrus and close to the inferior limiting sulcus of the insula. located and clipped.
Because of the severe subarachnoid and subpial hemorrhage, Different surgical techniques to clip MCA aneurysms have
it was difficult to identify the sulci and gyri. The location of the been reported that can basically be divided into the following
pars triangularis was estimated at approximately 2 cm behind 3 categories (3, 17, 18): the medial-to-lateral, lateral-to-medial,
the lateral edge of the frontal lobe, and the rest of the opercu- and superior temporal gyrus approaches.
lum was subsequently determined. The medial-to-lateral approach (31, 35) starts with opening
The posterior ramus of the sylvian fissure was opened wide the carotid cistern, followed by opening the stem of the sylvian
from the pars triangularis that covers the insular apex, anterior, fissure, which is then opened in a medial-to-lateral direction to
and middle short insular gyri to the postcentral gyrus for prox- expose the aneurysm. This technique allows early proximal
imal control and early identification of the parent artery. The control of the parent artery before the aneurysm is exposed.

WEN ET AL.
The lateral-to-medial approach (11) starts with opening the parietal opercula is roughly constant, except for the pars trian-
distal sylvian fissure, followed by tracing the MCA branches to gularis, throughout the lateral sylvian fissure. It can increase
the aneurysm and to the MCA trunk. risks to retract these opercula to expose the upper portion of the
In the superior temporal gyrus approach (6, 9), the MCA insula, especially with the insula of the dominant hemisphere.
aneurysm is approached through the superior temporal gyrus, Hence, the alternative is to retract the temporal operculum.
and subpial resection is used to expose the MCA branches and Among the 3 parts of the temporal operculum, only the planum
the aneurysm neck. polare (opposite pars triangularis, opercularis, and precentral
This technique offers the advantage of decreasing brain gyrus) presents a formidable depression that allows retraction,
retraction and manipulation of the MCA trunk and its perfora- creating more space to approach the superolateral facet of the
tors. The drawback is the potential to increase the risk of post- anterior zone. From the planum polare posteriorly, the oper-
operative epilepsy, and this technique is not suitable for an cula of the postcentral, supramarginal gyri, Heschl’s gyrus, and
aneurysm arising from a short MCA trunk. planum temporale present flat surfaces on the sylvian fissure,
The use of image-guidance navigation, thin-slice magnetic making their retraction more difficult and consequently making
resonance imaging (MRI) for image guidance, to locate and access to the posterior half of the insula more difficult.
treat unruptured MCA aneurysms has been reported by Son Case 1. The patient was a 17-year-old boy with a 4-year his-
et al. (17). The main advantages of this technique include small tory of complex partial seizures. MRI revealed a right-side insu-
incision and small craniotomy. lar tumor and a right frontal arachnoid cyst (Fig. 17A). The
For distal MCA aneurysm, Dashti et al. (4) recommend the insular tumor was well circumscribed and occupied the poste-
use of digital subtraction angiography, 3-dimensional CT- rior two-thirds of the insula (Fig. 17B). The superior limit was
angiography, T2-weighted MRI (coronal, axial) for preoperative located at the same level of the lateral opercular compartment of
planning and the use of neuronavigation, intraoperative nonin- the sylvian fissure (Fig. 17C). The patient underwent right pte-
vasive digital subtraction angiography, and color Doppler rional craniotomy with intraoperative electrocorticography in
ultrasonography for MCA aneurysms arising distal to the M2- August 2000 (Fig. 17D). The tumor was totally removed through
M3 junction. sylvian fissure (histology revealed pilocytic astrocytoma) (Fig.
In our surgical technique, the angiogram is analyzed and the 17E). The frontal cortex under the arachnoid cyst was resected
location of the aneurysm relative to the genu of the MCA and as well because of persistent spikes. The postoperative course
the direction of its dome are established. This information is was uneventful, and the patient remains free of seizures, anti-
taken into consideration in the pterional approach. To locate convulsant medication, and tumors (Fig. 17, F and G).
distal MCA aneurysms intraoperatively, it is important to know In this case, the relatively low upper limit of the tumor made
the relationship between the frontal, parietal, and frontoparietal the surgery easier. The upper limit of the tumor could be reached
opercula to the lateral surface of the insula and to the temporal as soon as the sylvian fissure was split; there was no need to
operculum. It is also important to understand that these rela- retract the frontal and parietal opercula during the surgery.
tionships are not a perfect match. For instance, the operculum Case 2. A 15-year-old girl had daily seizures since 1 year of
of the postcentral gyrus is in opposition to the Heschl’s gyrus. age. MRI revealed an image compatible with cortical dysplasia,
This does not mean that the anterior and posterior edges of the composing the anterior margin of the anterior insula cleft, pars
postcentral gyrus will precisely meet the anterior and posterior triangularis, and opercularis and the anterior half of the insula
edges of the Heschl’s gyrus, but most of the parts will be in on the right hemisphere (Fig. 18, A and B). She underwent a
opposition. This can also be extended to the insula and its over- right pterional craniotomy followed by a transsylvian approach
lying opercula: the operculum of the precentral gyrus most and removal of suspicious tissue in March 2006 (histology
likely will cover the middle third and part of the posterior third revealed cortical dysplasia) (Fig. 18, C and D). The postopera-
of the lateral surface of the insula. tive course was uneventful, and postoperative MRI performed
Aneurysms pointing upward are related to lenticulostriate 8 months after the surgery showed resection of the dysplasia
arteries when located in the proximal half of M1 or to (Fig. 18, E and F). She presented significant improvement in
orbitofrontal arteries when located in the distal half. Those that seizure frequency (1 nocturnal seizure every 3–4 weeks) but is
point downward are related to the anterotemporal arteries. still on anticonvulsants.
Case 3. The patient was a 26-year-old woman with com-
Insular Resections plex partial seizures since the age of 10 years. MRI revealed a
It is necessary to split the sylvian fissure wide and separate small cavernoma located on the long gyrus of the right insula;
the frontal and parietal opercula from the temporal operculum it was difficult to identify the posterior long gyrus in this case
to expose the insula. (Fig. 19, A–C). In March 2001, she underwent surgery via a
Although the insula is almost evenly covered by frontal, pari- right pterional transsylvian approach with total removal of the
etal, and temporal opercula, it is more difficult to expose the lesion (histology revealed cavernoma) (Fig. 19, D and E). The
lesions located in the superolateral facet of the insula than in the postoperative course was uneventful, but she presented 2 com-
inferolateral facet. It is easier to approach the anterior half of the plex partial seizures in the first month after the surgery, after
insula than its posterior half, mainly because of the morphology which she had no more seizures (Fig. 19, F and G). Currently,
of the temporal operculum; the morphology of the frontal and she is anticonvulsant free as well.

A B C
D E
FIGURE 17. A, sagittal MRI scan of the right hemisphere, depicting an F G

insular tumor and a frontal arachnoidal cyst. B, axial MRI scan. The tumor
occupies the posterior two-thirds of the insula, sparing the first 2 short gyri
(anterior and middle short gyri) and also sparing the posterior long gyrus.
The tumor is limited medially by the lentiform nucleus. C, coronal MRI
scan. The superior limit of the tumor is located at the same level of the lat-
eral opercular compartment of the sylvian fissure. D, surgical exposure after
an extended right pterional craniotomy, followed by the dural opening and
the sylvian fissure splitting. M2, insular segment of the MCA; In, insula.
Note that the tumor has encased the MCA. E, final aspect of the brain after
tumor removal. The branches of the MCA were preserved. The whitish
color of the arteries was owing to frequent application of the papaverine to
prevent vasospasm. F, postoperative coronal MRI scan performed 8 months
after surgery. G, postoperative axial MRI scan performed 8 months after
surgery. The arrow indicates the frontal resection.
In this case, the low location of the cavernoma in the insula Case 4. A 4-year-old boy had complex partial seizures since
favored the transsylvian approach. It was easier to retract the the age of 3 years. He underwent brain surgery previously at
temporal lobe than the frontal or parietal opercula because of another neurosurgical center, but apparently no sample of the
the planum polare. The proximity of the cavernoma to the tumor could be obtained, and the seizure frequency remained
retroinsular region made this surgery more dangerous to the unchanged. MRI revealed a tumor arising from the posterior
posterior portion of the posterior limb of the internal capsule; half of the right insula (Fig. 20, A and B). Apparently, the pre-
as discussed earlier, at this location, there is no interposition of vious surgery reached only the anterior zone of the insula (Fig.
the lentiform nucleus between the insula and the posterior limb 20C). He underwent an extended pterional craniotomy
of the internal capsule (Fig. 19F). (extended posteriorly to include the posterior end of the pos-

WEN ET AL.
A B C
D
E F
FIGURE 18. A, axial MRI scan. B, coronal MRI scan at the anterior part of lar segment of the MCA; In, insula. Asterisk, cortical dysplasia. D, intraop-
the insula. Note that the superolateral insular cleft on the right side is lack- erative photograph after the removal of the cortical dysplasia. E, postoperative
ing. Arrows indicate the cortical dysplasia. C, surgical exposure after right coronal MRI scan showing the resection of the cortical dysplasia. F, postop-
pterional craniotomy, dural opening, and sylvian fissure splitting. M2, insu- erative axial MRI scan.
terior ramus of the sylvian fissure) and transsylvian approach between the postcentral gyrus and the Heschl’s gyrus and not
in September 2005 with adequate removal of the tumor (Fig. at the level of the planum polare.
20, D and E) (histology revealed a grade II astrocytoma). The Once again, as stated in Case 3, the posteromedial limit of the
postoperative course was uneventful; he remains seizure-free tumor was immediately adjacent to the posterior limb of the
since the surgery and still takes anticonvulsant medication internal capsule, without the intervening lentiform nucleus.
(Fig. 20F). Knowledge of the overall shape of the insula is very impor-
In this case, the knowledge of the anatomy of the insula and tant in resecting intrinsic lesions that stay inside the boundaries
the surrounding frontal, parietal, and temporal opercula could of the insula, as in some gliomas of the insula. It is important
have helped the surgeon who performed the first surgery. MRI for surgeons to bear in mind that the anterior insula is com-
clearly showed that the tumor was located in the posterior half posed of a pyramid with its apex pointing downward and the
of the insula; the middle and posterior portions of the insula posterior insula extends from the retroinsular region to the
were covered on the surface by the operculum of the precentral anterior pole of the insula.
and postcentral gyri. The latter meets the junction of the supe- The superomedial, inferomedial, and the posteromedial
rior temporal gyrus and the Heschl’s gyrus at the coronal plane limits of insular resection are the normal white matter, i.e.,
above the external acoustic meatus. Therefore, after opening the corona radiata superiorly, retrolentiform portion of the
wide the posterior ramus of the sylvian fissure, the approach to internal capsule and temporal stem inferiorly, and retrolen-
the tumor should have been centered at the level of the junction tiform portion of the internal capsule posteriorly. At the cen-

and lentiform nucleus) will

A B C be encountered as the medial
limits of the resection,
depending on the medial
extension of the lesion.

The resection involving the
anterior surface of the insula

is equally challenging. It is
very important to bear in
mind the overall sickle shape
of the inferolateral facet of the
insula. It is also important to
keep in mind especially the
medial boundary of the ante-
D F rior surface of the insula: it is
shallower in its upper portion
that ends at the very anterior
limb of the internal capsule

and deeper in its lower por-
tion that ends at the postero-
medial orbital lobule, located
laterally to the olfactory sul-
cus and above the apparent
posterior end of the olfactory
tract.
Hence, the theoretical limits
for anterobasal insular resec-
tions are as follows: the antero-
G medial limit is the anterior
portion of the anterior limb of
the internal capsule, the pos-
terolateral limit is the insular
E pole, and the posteromedial
limit is the anterior perforated
substance. The intraoperative
anatomic landmark for the
posterior limit of the anter-
FIGURE 19. A, sagittal MRI scan obasal resection is the M1 seg-
depicting a cavernoma located in ment of the MCA. The medial
the long gyrus of the insula, limit of the inferomedial resec-
approximately halfway between the tion of the anterior surface of
superior and the inferior limiting the insula is the olfactory tract.
sulci. B, axial MRI scan. C, coronal Obviously, the limits of re -
MRI scan. D, intraoperative photo- section must be very well
graph after the right pterional-
evaluated preoperatively and
transsylvian approach. The arrow
tailored according to each par-
indicates the cavernoma located on
the sole long gyrus of the insula. ticular case.
T h e a r ro w h e a d i n d i c a t e s t h e Although quite similar, the
Heschl’s gyrus that prevented fur- actual microsurgery differs
ther lateral retraction of the temporal lobe. E, intraoperative photograph after the removal of the cavernoma. F, post- from the anatomic dissection
operative CT scan 1 day after surgery. Note the proximity of the resection cavity to the posterior limb of the inter- in that the former requires
nal capsule. G, postoperative MRI performed 3 months after the surgery showed total resection of the cavernoma. additional information acquir-
ed from imaging. An intrinsic
insular lesion will remain con-
tral region of the lateral surface of the insula, white matter fined within the insula in most cases and will still be projected
(extreme and external capsules) or gray matter (claustrum on the lateral surface of the cerebrum from the horizontal ramus

WEN ET AL.
important because the surgeon

A B C has to work between and also
preserve the branches of the
M2 segment. Usually, the
expanded insula with a tumor

will come into the surgeon’s
view as soon as the sylvian fis-

sure is split. Sometimes the
major M2 branches cannot be
identified promptly because
each insular gyrus will be
expanded, and the insular sulci
containing the M2 branches
will be trapped between the
E F enlarged gyrus, hiding the
MCA branches. In this case,
early debulking of the tumor
or debulking of the enlarged

gyri can facilitate identification
of the insular sulci and MCA
branches.
Once the tumor has been
debulked and the major M2
branches identified, it is advi-
sable to first find the inferior
and anterior limiting sulci of
the insula to establish the infe-
rior, inferoposterior, and ante-
rior limits of the insula. Fre-
quently, the transition between
the insula and the planum
polare is also infiltrated by the
FIGURE 20. A, sagittal MRI scan. The tumor occupies the posterior zone of
G tumor. Hence, the early re -
moval of this portion of the
the right insula. The previous surgery apparently reached the anterior portion
of the insula (arrows). B, axial MRI scan. The tumor occupies the posterior
tumor will create additional
part of the insula. The posteromedial limit of the tumor is closely related to the room in the planum polare,
posterior limb of the internal capsule; there is no intervening lentiform facilitating the work in the
nucleus at this point. C, coronal MRI scan. The previous surgery removed insula.
both the temporal and frontal opercula and also the anterior portion of the Removing the upper por-
insula. Note that the insula edge is still prominent at this cut on the left side, tion of the tumor is challeng-
indicating that this is the anterior insula. D, intraoperative photograph after ing, especially in the dominant
opening the posterior ramus of the sylvian fissure. The tumor (whitish tissue) h e m i s p h e re , b e c a u s e t h e
occupies the posterior zone of the insula. E, intraoperative photograph after retraction over the frontal and
the tumor removal. F, postoperative axial MRI scan depicting the resection of
parietal opercula can cause
the tumor.
neurological deficits. It is
sometimes advisable to debulk
the tumor as much as possible
to the supramarginal gyrus. It is interesting to evaluate the thick- and then try to pull out the pial surface of the upper insula like
ness of the medial extent of the tumor as well as the maximum the capsule of an extrinsic tumor, followed by debulking the
AP length and height of the tumor on the preoperative MRI. tumor again. This maneuver can be performed successively
The technical nuances of intrinsic insular tumor resection rather than retracting the frontal and parietal opercula to resect
have been magnificently pioneered and reported by Yaşargil the upper insula.
(32) and Yaşargil and Fox (34), and some details are still worth To establish the medial limit of the resection for insular
mentioning. tumors can be challenging as well. The lentiform nucleus can
Some important aspects involving insular resection can be serve as a barrier preventing surgeons from trespassing toward
pointed out. The early identification of MCA branches is very the internal capsule. The lentiform nucleus presents the look of

A B C D
E F
FIGURE 21. A, axial MRI scan depicting G H I

a left frontal tumor. B, coronal MRI scan.
C, sagittal MRI scan depicting a tumor
arising from the frontobasal region. D,
sagittal MRI scan. The arrowhead indi-
cates the anterior insular cleft. The tumor
is confined in the fronto-orbital area. E,
intraoperative photograph after a left pte-
rional craniotomy and dural opening. The
letters indicate epileptiform spikes in the
left frontal lobe. F, intraoperative photo-
graph showing the opening of the anterior
insular cleft. The anterior surface of the
insula was covered by the cottonoid. G,
postoperative axial MRI scan. H, postoperative coronal MRI scan. I, postoperative sagittal MRI scan. The mediotemporal structures also were removed.
gray matter. However, the lentiform nucleus is a small shield branches originating from the M2 segment of this region that
leaving the anterior (anterior limb), superior (corona radiata), directly supply the internal capsule (23).
posterior (retrolentiform), and inferior (sublentiform) parts of Under normal conditions, the length of the superior limiting
the internal capsule uncovered. sulcus, the AP extent, of the insula is approximately 5 cm, and
The resection of a posterior insular lesion can be difficult the height of the anterior limiting sulcus of the insula is
because of the retraction over the Heschl’s gyrus and the approximately 3 cm. The length of the insula and the limiting
planum temporale and the supramarginal and postcentral gyri. sulci of each patient can be determined accurately by preoper-
Caution should be used because there have been reports of ative MRI.

WEN ET AL.
A B C
FIGURE 22. A, axial MRI scan. There is an D E

increase in signal over the posteromedial

orbital lobule. B, coronal MRI scan. There is
a thin layer of white matter separating the
suspicious area (corresponding to the pos-
teromedial orbital lobule) from the inferior
portion of the caudate nucleus. C, intraoper-
ative photograph of the second operation,
after a right pterional craniotomy and dural
opening. 1, olfactory tract; 2, suspicious tis-
sue; 3, optic chiasm and carotid artery; M1,
M1 segment of the MCA; A1, precommuni-
cating segment of the anterior cerebral
artery. At the tip of the suction tube is the
posterior part of the olfactory tract. D, intra-
operative photograph after removal of the
posteromedial orbital lobule and the rectus gyrus. 1, olfactory tract; 2, ante- precommunicating segment of the anterior cerebral artery. E, postoperative
rior cerebral artery in the interhemispheric fissure; 3, lenticulostriate arter- MRI scan performed 5 days after surgery showed the resection of the fronto-
ies arising from the carotid bifurcation; M1, M1 segment of the MCA; A1, basal area, just anterior to the carotid artery bifurcation.
Ausman et al. (1) reported an intraoperative localization tumor growing from the left frontobasal area pushing the
technique for resecting vascular lesions around the sylvian insula backward (Fig. 21, A–C), with good identification of the
point by following major arteries that exit the posterior portion anterior insular cleft (Fig. 21D). In December 2003, she under-
of the sylvian fissure, e.g., the angular artery, and splitting only went left pterional craniotomy and intraoperative electrocor-
the necessary extent of the sylvian fissure. ticography (Fig. 21E). The anterior insular cleft was split to
determine the posterior limit of resection (Fig. 21F). The resid-
Frontobasal Resections ual medial temporal structures also were removed (histology
In resections involving the basal portion of the frontal lobe, revealed pilocytic astrocytoma). The postoperative course was
it is important to evaluate the superior and posterior limits of uneventful, and she has remained seizure free since the surgery
the lesion because of its proximity to the anterior surface of the and is on a gradual withdrawal regimen of anticonvulsant
insula and to the anteroinferior surface of the basal ganglia. medication (Fig. 21, G–I).
Case 1. The patient was a 17-year-old girl with mental retar- In this case, the initial approach was to identify the horizontal
dation and refractory epilepsy (complex partial seizures) since ramus that continues medially with the anterior insular cleft to
the age of 5 years. At the age of 10 years, she underwent par- determine the anterior limit of the insula and to estimate the loca-
tial left temporal lobectomy with removal of a tumor (pilocytic tion of the head of the caudate nucleus. The entry into the tumor
astrocytoma) and evacuation of a postoperative extradural was performed via the pars orbitalis. Because of the very distinc-
hematoma at another neurosurgical center, without adequate tive aspect of the tumor, which was quite different from normal
postoperative seizure control. At the age of 11 years, she under- brain tissue, it was not difficult to remove the whole tumor.
went another temporal resection for residual tumor. At the age Case 2. A 17-year-old girl had 3 different types of daily
of 13 years, she was referred to our hospital. MRI revealed a seizures (complex partial, tonic, and generalized tonic-clonic)

A B
C D
FIGURE 23. A, intraoperative photograph after an extended right pterional

transsylvian approach, depicting the inferior limiting sulcus of the insula
(between the tips of the bipolar forceps). 1, temporal lobe; 2, insula; 3, frontal insula. Asterisk, choroid plexus of the temporal horn. D, intraoperative pho-
lobe. B, intraoperative photograph after entering the temporal horn. 1, head tograph after a right pterional transsylvian selective amygdalohippocampec-
of the hippocampus; 2, choroid plexus, temporal stem, and the M2 segment tomy. 1, free edge of the tentorium; 2, dura mater of the floor of the middle
of the MCA. The Heschl’s gyrus has been retracted posteriorly by the bipolar fossa; 3, P2A segment of the posterior cerebral artery, and the choroid plexus
forceps. C, anatomic dissection mimicking the surgical approach shown in B. of the temporal horn; 4, M2 segment of the MCA; 5, Heschl’s gyrus; III, ocu-
1, superior temporal gyrus; 2, head of the hippocampus; 3, Heschl’s gyrus; 4, lomotor nerve.
since the age of 5 years. The preoperative investigation pletely new preoperative workup for epilepsy, the neurolo-
included electroencephalography, video-electroencephalo- gists still could not determine precisely the origin of the
graphic monitoring, and ictal and interictal single-photon seizures. Because of the severity of the illness, she again
emission CT, but did not indicate precisely the origin of the underwent a right pterional craniotomy (Fig. 22C) with total
seizures. MRI showed an increased signal on the right fronto- resection of the frontobasal area and removal of the frontal
basal area (Fig. 22, A and B). In July 2003, she underwent right pole (Fig. 22, D and E). The postoperative course was
pterional craniotomy with electrocorticography, and the lat- uneventful, but the seizures gradually resumed 1 week after
eral orbital gyrus, where the epileptiform spikes were evi- the surgery, and the histology results remained unclear.
dent, and the lateral part of the posteromedial orbital lobule, In cases such as this, when the resection of the suspicious tis-
with no spikes, were resected. Despite the surgery, her sue is solely based on anatomic landmarks, the knowledge on
epilepsy remained unchanged. In August 2007, after a com- the anatomy of the frontobasal area becomes essential.

WEN ET AL.
A The major areas of concern in dealing with frontobasal

lesions are the anterior perforated substance and lenticulostri-
ate arteries and the anteroinferior portion of the basal ganglia.
The anterior limit of the anterior perforated substance has
been classically described as medial and lateral olfactory striae

(12, 15). However, it is extremely difficult to identify the striae
intraoperatively.
From a practical viewpoint, the anterior limit of the perforated
substance can be considered the accessory gyrus of Ebertaller lat-
erally and the posterior edge of the rectus gyrus medially.
It is interesting to note that even in the frontobasal area, the
claustrum accompanies the inferolateral facet of the insula and
stays interposed between the extreme and external capsules. There
is no claustrum above the posteromedial orbital lobule (Fig. 6E).
From a microneurosurgical standpoint, the anterior perforated
substance indicates more than just the entry site for the lenticulos-
triate arteries to the basal ganglia or the exit site for the inferior
striate vein from the basal ganglia; it is the site where the anteroin-
ferior portion of the lentiform nucleus (the globus pallidus medi-
ally and the putamen laterally) comes to the surface. Part of the
anterosuperior portion of the basal ganglia, i.e., the caudate
nucleus, also comes to the surface intraventricularly as the lateral
walls of the frontal horn and the body of the lateral ventricle.
Intraoperatively, the presence of lenticulostriate vessels and a
B sudden increase in bleeding indicate entry into basal ganglia.
Amygdalohippocampectomy and Hemispherotomy

The inferior limiting sulcus of the insula as the preferred
route to enter the temporal horn in transsylvian amygdalohip-
pocampectomies has been advocated and popularized by
Yaşargil et al. (36). Figure 23, A–D, shows the sequence of a
right transsylvian selective amygdalohippocampectomy.
The first author (HTW) has performed most of the amyg-
dalohippocampectomies via the superior temporal gyrus. In
these cases, the temporal horn is entered by following the gray
matter overlying the occipitotemporal sulcus (27, 29). The supe-
rior temporal gyrus is then peeled off subpially from the arach-
noidal membrane of the sylvian fissure to reach the inferior
limiting sulcus of the insula (Fig. 24A). The next step is to con-
nect the bottom of the inferior limiting sulcus of the insula to
the temporal horn by cutting the temporal stem.
In peri-insular hemispherotomy or hemispherical deafferenta-
FIGURE 24. A, intraoperative photograph showing a right amygdalohip-
pocampal resection via superior temporal gyrus. The right temporal horn,
tion, the rationale of the procedure is to disconnect the cerebral
superior temporal gyrus, and uncus have been peeled off from the arach- hemisphere around its central core (26). As part of this proce-
noidal membrane of the sylvian fissure and carotid cistern. The tip of the dure, the early identification of the anterior insular cleft indi-
suction tube (on the left) is located immediately ahead of the inferior cates the anterior limiting sulcus of the insula, which, in turn,
choroidal point. Both tips of the bipolar forceps are inside the temporal ultimately indicates the anterior limit of the basal ganglia that
horn. 1, arachnoidal membrane of the temporal pole; 2, carotid artery (cov- should not be trespassed on during the procedure (Fig. 24B).
ered by arachnoidal membrane); 3, M1 segment of the MCA just before the The resection of the amygdala can be performed either sub-
genu of the MCA; 4, beginning of the inferior limiting sulcus of the insula; pially or intracisternally. The relationships between the tempo-
5, superior temporal gyrus; 6, choroid plexus of the temporal horn. ral amygdala and the globus pallidus and the landmarks for
Asterisk, anteromedial surface of the uncus that has been peeled off from
resecting the temporal amygdala have been reported in an ear-
the arachnoidal membrane of the carotid cistern. B, intraoperative photo-
graph of the initial phase of a right hemisphere deafferentation (after split-
lier publication by Wen et al. (29). Because of the proximity of
ting the sylvian fissure). 1, insula; M2, insular segment of the MCA. The the inferior choroidal point and the anatomic complex formed
arrowheads indicate anterior insular cleft. by the optic tract, apex of the uncus, and upper portion of the
crus cerebri (Fig. 6B), the resection of the apex of the uncus

should not extend above the level of the inferior choroidal 12. Rhoton AL Jr: The cerebrum. Neurosurgery 53 [Suppl 2]:29–148, 2003.
point because of the risk of entering the globus pallidus and the 13. Rhoton AL Jr: The supratentorial arteries, in Rhoton Cranial Anatomy and
Surgical Approaches. Baltimore, Lippincott Williams & Wilkins, 2003, pp
risk of injuring the optic tract and the anterior choroidal artery.
81–148.
In this article, we aimed to share our experience in anatomic 14. Ring BA: The middle cerebral artery, in Newton TH, Potts DG (eds): Radiology
dissection combined with its application in neuroimaging, sur- of the Skull and Brain. St. Louis, CV Mosby, 1974, pp 1442–1478.
gical planning, and microsurgery performed in and around the 15. Rosner SS, Rhoton AL Jr, Ono M, Barry M: Microsurgical anatomy of the
sylvian fissure region. We hope that the information in this anterior perforating arteries. J Neurosurg 61:468–485, 1984.
16. Schlesinger B: The insulo-opercular arteries of the brain, with special refer-
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much as we did, but in less time. Med 70:555–563, 1953.
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CONCLUSION 18. Stoodley MA, Weir BKA: Surgical treatment of middle cerebral artery
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The anatomic information regarding the sylvian fissure Cerebral Aneurysms. Philadelphia, Saunders, 2004, pp 795–807.
19. Szikla G, Bouvier T, Hori T, Petrov V: The sylvian fissure, in Angiography of the
region has been very helpful for the authors in preoperative
Human Brain Cortex. Berlin, Springer, 1977, pp 101–125.
planning and has provided reliable intraoperative navigation 20. Tanriover N, Rhoton AL Jr, Kawashima M, Ulm AJ, Yasuda A: Microsurgical
landmarks in microsurgeries involving that region performed anatomy of the insula and the sylvian fissure. J Neurosurg 100:891–922, 2004.
over the past 15 years. 21. Taveras JM, Pile-Spellman J: Neuroradiology. Baltimore, Williams & Wilkins,
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Despite the current technological advances in targeting, nav-
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igating, and controlling surgical procedures, many anatomic, insular region. J Neurosurg 90:720–733, 1999.
imaging, preoperative planning, and surgical details are still 23. Türe U, Yaşargil MG, Al Mefty O, Yaşargil DCH: Arteries of the insula. J
out of reach using these technologies. When well trained, the Neurosurg 92:676–687, 2000.
surgeon’s own mind seems to be the best available computer 24. Waddington MM: Atlas of Cerebral Angiography with Anatomic Correlation.
Boston, Little Brown and Company, 1974, ed 1, pp 38–41.
for analyzing the nuances of neuroimages, defining the opera- 25. Wen HT, Mussi AC, Rhoton AL Jr: Surgical anatomy of the brain, in Winn HR,
tive approach, planning a treatment strategy, performing Youmans JR (eds): Youmans Neurological Surgery. Philadelphia, WB Saunders,
microsurgery, and optimizing the benefits provided by cur- 2003, ed 5, pp 5–44.
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tomy and their clinical application. J Neurosurg 101:747–755, 2004.
27. Wen HT, Rhoton AL Jr, Marino R Jr: Gray matter overlying anterior basal tem-
Disclosure
poral sulci as an intraoperative landmark for locating the temporal horn in
The authors have no personal financial or institutional interest in any of the amygdalohippocampectomies. Neurosurgery 59 [Suppl 4]:221–227, 2006.
drugs, materials, or devices described in this article. 28. Wen HT, de Oliveira E, Tedeschi H, Andrade FC Jr, Rhoton AL Jr: The pteri-
onal approach: Surgical anatomy, operative technique, and rationale.
Operative Techniques in Neurosurgery 4:60–72, 2001.
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Marino R Jr: Microsurgical anatomy of the temporal lobe: Part 1. Mesial tem-
1. Ausman JI, Dias FG, Malik GM, Tomecek F: A new microsurgical approach to
poral lobe anatomy and its vascular relationships as applied to amygdalohip-
cerebrovascular lesions of the sylvian point: Report of two cases. Surg Neurol
pocampectomy. Neurosurgery 45:549–592, 1999.
34:48–51, 1990.
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31. Yaşargil MG: Operative anatomy, in Microneurosurgery. Stuttgart, Thieme,
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1984, pp 36–39, 72–91, vol 1.
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32. Yaşargil MG: Limbic and paralimbic tumors, in Microneurosurgery. Stuttgart,
Albayrak BS, Ronkainen A, Koivisto T, Jääskeläinen JE: Microneurosurgical
Thieme, 1996, pp 252–290, vol 4B.
management of distal middle cerebral artery aneurysms. Surg Neurol
33. Yaşargil MG: A legacy of microneurosurgery: Memoirs, lessons, and axioms.
67:553–563, 2007.
Neurosurgery 45:1025–1092, 1999.
5. Gibo H, Carver CC, Rhoton AL Jr, Lenkey C, Mitchell RJ: Microsurgical
34. Yaşargil MG, Fox JL: The microsurgical approach to intracranial aneurysms.
anatomy of the middle cerebral artery. J Neurosurg 54:151–169, 1981.
Surg Neurol 3:7–14, 1975.
6. Heros RC, Ojemann RG, Crowell RM: Superior temporal gyrus approach to
35. Yaşargil MG, Cravens GF, Roth P: Surgical approaches to “inaccessible” brain
middle cerebral artery aneurysms: Technique and results. Neurosurgery
tumors. Clin Neurosurg 34:42–110, 1988.
10:308–313, 1982.
36. Yaşargil MG, Teddy PG, Roth P: Selective amygdalo-hippocampectomy oper-
7. Krayenbühl H, Yaşargil MG, Huber P, Bosse G: Cerebral Angiography Stuttgart, ative anatomy and surgical technique, in Symon L, Brihaye J, Guidetti B,
Thieme, 1982, ed 2, pp 105–121. Loew F, Miller JD, Nornes H, Pásztor E, Pertuiset B, Yaşargil MG (eds):
8. Microsoft Bookshelf 1999 Computer and Internet Dictionary. Redmond, Microsoft Advances and Technical Standards in Neurosurgery, Vienna, Springer-Verlag,
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9. Ogilvy CS, Crowell RM, Heros RC: Surgical management of middle cerebral
artery aneurysms: Experience with transsylvian and superior temporal gyrus
approaches. Surg Neurol 43:15–24, 1995. Acknowledgment
10. Ono M, Kubik S, Abernatehey CD: Atlas of the Cerebral Sulci. Stuttgart, We thank the University of Florida for sponsoring the publishing expenses for
Thieme, 1990, pp 94–110. this article. We thank Toshiro Katsuta, M.D., Ryusui Tanaka, M.D., for partner-
11. Pritz MB, Chandler WF: The transsylvian approach to middle cerebral artery ship and collaboration; Ms. Tana Silva and Mrs. Cecília Emi Tsukamoto for
bifurcation/trifurcation aneurysms. Surg Neurol 41:217–220, 1994. preparing the manuscript.

WEN ET AL.
COMMENTS linked the imaging to detailed dissection and the authors’ surgical
expertise. The study of the sylvian fissure is particularly pertinent, as
T he sylvian fissure is, indeed, the main corridor of the brain and, for
us neurosurgeons, one of the regions most frequently dealt with
during microsurgical procedures. In this well-written article, Wen et al.
it is correctly described as being the “main corridor” to the brain. This
scholarly study is a continuation of the authors’ report on the anatomy
of the temporal lobe, previously published in Neurosurgery in 1999,
meticulously summarize the anatomic data abutting the region of the and it superbly amalgamates their surgical observations with the
sylvian fissure obtained from more than a decade of anatomic and details of dissection and neuroimaging. It would seem that it has been
intraoperative studies. This report contains the work and experience of 15 years in the making, and it has certainly been worth the wait. The
a group of neurosurgeons well known in the neurosurgical community authors present a superb scholarly study that “modernizes” anatomy
for their achievements in neuroanatomy, among other specialties. A lot for the neurosurgeon.
of important details are given, related to cerebral and cerebrovascular
anatomy and how one should apply this profound knowledge in daily Andrew H. Kaye
neurosurgical practice when performing neurovascular, neuro-onco- Melbourne, Australia
logical, or epilepsy surgery.
New terms have been proposed for the anterior and lateral opercu-
loinsular compartments. Their clinical usefulness, however, remains F amiliarity with the sylvian fissure and appreciation of its value as a
surgical corridor are first acquired by most neurosurgeons in the
context of aneurysm surgery. With a growing recognition of the impor-
to be proven. Nevertheless, the authors have provided many illustra-
tions of high-quality anatomic dissections. This material is particularly tance of such structures as the frontal, temporal, and parietal opercula,
illustrative and helpful for young neurosurgeons and may serve as a the insula, and the orbitofrontal cortex in tumor and epilepsy surgery,
basic reference for studying the anatomically difficult region of the syl- a solid anatomic understanding of this surgical approach and its
vian fissure. anatomy is proving invaluable across a broader spectrum of neuro-
Interestingly, the authors mention the obviously limited anatomic surgery. As helpful and essential as intraoperative guidance and imag-
knowledge of young neurosurgeons, a current phenomenon that, in ing technology have become, neuroanatomic grounding is requisite. In
our opinion, should continuously challenge all those who like teaching this review, Wen et al. provide an articulate and well-illustrated guide
neurosurgery and neuroanatomy in a similar fashion as done by the to this region that will be useful to cerebrovascular, tumor, and epilepsy
present authors. In summary, this article, with its numerous images and surgeons alike.
anatomic details, is certainly another milestone of neuroanatomic per- With respect to tumor resection, knowledge of the anatomy can be
formance. critically aided by the complementary information provided through
functional mapping. Unlike the predominantly extra-axial dissection
Oliver Bozinov of cerebrovascular surgery, resection for either tumor or epilepsy can
Niklaus Krayenbühl be facilitated and made safer with knowledge of speech and motor
Helmut Bertalanffy representation. In insular resection, subcortical mapping may pro-
Zürich, Switzerland vide the most secure definition of corticospinal pathways medially.
Throughout the resection, continuous monitoring of motor evoked
W en et al. have completed an extraordinary article about the

microsurgical anatomy of the sylvian fissure. This report pro-
vides original descriptions and concepts of the insular edge and the
potentials can provide peace of mind. On the language-dominant
side, delineation of speech-related areas will guide the posterior
extent of resection in the insula. Two recent reports by Duffau (1)
anterior and lateral operculoinsular compartments, which are useful for and by Simon et al. (2) well illustrate the current capabilities of
understanding the complex 3-dimensional anatomy of the sylvian fis- lesional resection in this region.
sure and insular region. Moreover, the article addresses the difficulties The greater difficulty in exposing the lateral aspect of the posterior
of interpreting cerebral angiograms and offers unique tips for accurate insula, as pointed out by Wen et al., has modified our own approach to
anatomoradiological correlations. As they did almost 10 years ago with intracranial investigation of intractable epilepsy in this region. Our
the publication of the first part of this study, Wen et al. have again pro- earliest investigations, placing subdural strip electrodes on the insula,
vided a landmark microsurgical anatomy work. have been replaced by depth electrode arrays, which, in this particular
setting, are a far easier, more reliable, and safer technique. At the time
Juan C. Fernandez-Miranda
of resection, mapping can be performed as appropriate.
Pittsburgh, Pennsylvania
With respect to selective amygdalohippocampectomy, Yaşargil’s
Neal F. Kassell transsylvian approach, in experienced hands, can be elegant, as the
Charlottesville, Virginia figures of this review illustrate. Personally, I prefer a transcortical, ante-
rior middle temporal gyrus approach, away from the more critical
structures highlighted in this article.
A natomy is the basic building block of surgery, and an in-depth
understanding of the details of neuroanatomy is an essential
requirement for neurosurgery. With the advances in microsurgical
David W. Roberts
Lebanon, New Hampshire
approaches, there is no anatomic detail that is so insignificant that it
shall not be committed to memory and analyzed as to how it will influ-
ence the operation, and there is no nuance of anatomy that should be
1. Duffau H: A personal consecutive series of surgically treated 51 cases of insu-
regarded as being insignificant. lar WHO Grade II glioma: Advances and limitations. J Neurosurg 110:696–708,
Although the extraordinary advances in neuroradiological imaging 2009.
have dramatically advanced our appreciation of both core anatomy 2. Simon M, Neuloh G, von Lehe M, Meyer B, Schramm J: Insular gliomas: The
and vascular anatomy, this study is particularly valuable as it has case for surgical management. J Neurosurg 110:685–695, 2009.

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ANATOMY

MICROSURGICAL ANATOMY OF THE TEMPORAL LOBE:

PART 2—SYLVIAN FISSURE REGION AND

ITS CLINICAL APPLICATION

Manoel Jacobsen Teixeira, M.D.

NEUROSURGERY VOLUME 65 | OPERATIVE NEUROSURGERY 1 | DECEMBER 2009 | ons1

demonstrate some of the clinical applications of that anatomic

The sylvian fissure is a fissure formed by the infolding of the

long gyrus courses anteroinferiorly to reach the most anteroinfe-

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fissure divides into the anterior horizontal, anterior ascending,

NEUROSURGERY VOLUME 65 | OPERATIVE NEUROSURGERY 1 | DECEMBER 2009 | ons3

planum polare, and the supra-

the planum temporale (com-

transverse temporal gyri)

view is located at the level of

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is located on the superior temporal gyrus and begins at the

The planum polare therefore presents 2 distinct morpholo-

gyrus to the “turning point” located at the level of the pars

ues medially as the anterior limiting sulcus of the insula (Fig.

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FIGURE 4. A, superolateral view of the left hemisphere. 1, precentral gyrus;

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anterior limiting sulcus (Fig.

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rior short gyrus; 2, middle short gyrus; Caudate N, head of the

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Substance versus Basal

The neural structure on the

Pars Triangularis, FIGURE 7. A, frontobasal view of the

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Clinical Application of Anatomic Information

tion is relevant because what is important to neurosurgeons

authors’ experience, most of the time, this distinction can only

be identified as the neural structure located immediately

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Heschl’s gyrus points toward

rior wall of the atrium.

bral hemisphere, composed

C cerebral artery (A2–A5 seg-

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FIGURE 12. A, lateral view of C D

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FIGURE 15. A, AP view of a left carotid angiography depicting an MCA

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FIGURE 16. A, axial CT scan. There is a