Microsurgical Anatomy of the Supracerebellar Transtentorial Approach to the Posterior Mediobasal Temporal Region: Technical Considerations With a Case Illustration

Abstract Objective: Surgical access to the posterior portion of the mediobasal temporal lobe presents a formidable challenge to neurosurgeons, and much controversy still exists regarding the selection of the surgical approach to this region. The supracerebellar transtentorial (SCTT) approach to the posterior mediobasal temporal region can be used as an alternative to the subtemporal or transtemporal approaches. The aim of this study was to demonstrate the surgical anatomy of the SCTT approach and review the gyral, sulcal, and vascular anatomy of the posterior mediobasal temporal lobe. The use of this approach in the resection of a ganglioglioma located in the left posterior parahippocam-pal gyrus is illustrated. Methods: The SCTT approach to the posterior parahippocampal gyrus was performed on three silicone-injected cadaveric heads. The gyral, sulcal, and arterial anatomy of the posterior mediobasal temporal lobe was studied in six formalin-fixed injected hemispheres. Results: The SCTT approach provided a direct path to the posterior mediobasal temporal lobe and exposed the posterior parahippocampal gyrus as well as the adjacent gyri in all of the cadaveric specimens. Through this approach, gross total resection of the ganglioglioma was possible in our patient. Conclusion: The SCTT approach provided a viable surgical route to the posterior mediobasal temporal lobe in the cadaveric studies. This approach provides an advantage over the subtemporal and transtemporal routes in that there is less temporal lobe retraction.

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Microsurgical Approaches to the Medial Temporal Region: An Anatomical Study

Operative Neurosurgery ◽

10.1227/01.neu.0000223509.21474.2e ◽

2006 ◽

Vol 59 (suppl_4) ◽

pp. ONS-279-ONS-308 ◽

Cited By ~ 14

Author(s):

Alvaro Campero ◽

Gustavo Tro´ccoli ◽

Carolina Martins ◽

Juan C. Fernandez-Miranda ◽

Alexandre Yasuda ◽

...

Keyword(s):

Anatomical Study ◽

Middle Part ◽

Surgical Anatomy ◽

Surgical Approaches ◽

Temporal Region ◽

Anterior Portion ◽

Posterior Portion ◽

Medial Surface ◽

Posterior Group ◽

Quadrigeminal Plate

Abstract OBJECTIVE: To describe the surgical anatomy of the anterior, middle, and posterior portions of the medial temporal region and to present an anatomic-based classification of the approaches to this area. METHODS: Twenty formalin-fixed, adult cadaveric specimens were studied. Ten brains provided measurements to compare different surgical strategies. Approaches were demonstrated using 10 silicon-injected cadaveric heads. Surgical cases were used to illustrate the results by the different approaches. Transverse lines at the level of the inferior choroidal point and quadrigeminal plate were used to divide the medial temporal region into anterior, middle, and posterior portions. Surgical approaches to the medial temporal region were classified into four groups: superior, lateral, basal, and medial, based on the surface of the lobe through which the approach was directed. The approaches through the medial group were subdivided further into an anterior approach, the transsylvian transcisternal approach, and two posterior approaches, the occipital interhemispheric and supracerebellar transtentorial approaches. @@RESULTS:@@ The anterior portion of the medial temporal region can be reached through the superior, lateral, and basal surfaces of the lobe and the anterior variant of the approach through the medial surface. The posterior group of approaches directed through the medial surface are useful for lesions located in the posterior portion. The middle part of the medial temporal region is the most challenging area to expose, where the approach must be tailored according to the nature of the lesion and its extension to other medial temporal areas. CONCLUSION: Each approach to medial temporal lesions has technical or functional drawbacks that should be considered when selecting a surgical treatment for a given patient. Dividing the medial temporal region into smaller areas allows for a more precise analysis, not only of the expected anatomic relationships, but also of the possible choices for the safe resection of the lesion. The systematization used here also provides the basis for selection of a combination of approaches.

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Left Transsylvian Transcisternal and Transinferior Insular Sulcus Approach for Resection of Uncohippocampal Tumor: 3-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy106 ◽

2018 ◽

Vol 15 (6) ◽

pp. E79-E80 ◽

Cited By ~ 1

Author(s):

Juan C Fernandez-Miranda

Keyword(s):

Temporal Lobe ◽

Medial Temporal Lobe ◽

Anterior Segment ◽

Temporal Cortex ◽

Surgical Anatomy ◽

Temporal Lobectomy ◽

Temporal Region ◽

3 Dimensional ◽

Selective Amygdalohippocampectomy ◽

Selective Approach

Abstract The medial temporal lobe can be divided in anterior, middle, and posterior segments. The anterior segment is formed by the uncus and hippocampal head, and it has extra and intraventricular structures. There are 2 main approaches to the uncohippocampal region, the anteromedial temporal lobectomy (Spencer's technique) and the transsylvian selective amygdalohippocampectomy (Yasargil's technique). In this video, we present the case of a 29-yr-old man with new onset of generalized seizures and a contrast-enhancing lesion in the left anterior segment of the medial temporal lobe compatible with high-grade glioma. He had a medical history of cervical astrocytoma at age 8 requiring craniospinal radiation therapy and ventriculoperitoneal shunt placement. The tumor was approached using a combined transsylvian transcisternal and transinferior insular sulcus approach to the extra and intraventricular aspects of the uncohippocampal region. It was resected completely, and the patient was neurologically intact after resection with no further seizures at 6-mo follow-up. The diagnosis was glioblastoma IDH-wild type, for which he underwent adjuvant therapy. Surgical anatomy and technical nuances of this approach are illustrated using a 3-dimensional video and anatomic dissections. The selective approach, when compared to an anteromedial temporal lobectomy, has the advantage of preserving the anterolateral temporal cortex, which is particularly relevant in dominant-hemisphere lesions, and the related fiber tracts, including the inferior fronto-occipital and inferior longitudinal fascicles, and most of the optic radiation fibers. The transsylvian approach, however, is technically and anatomically more challenging and potentially carries a higher risk of vascular injury and vasospasm. Page 1 and figures from Fernández-Miranda JC et al, Microvascular Anatomy of the Medial Temporal Region: Part 1: Its Application to Arteriovenous Malformation Surgery, Operative Neurosurgery, 2010, Volume 67, issue 3, ons237-ons276, by permission of the Congress of Neurological Surgeons (1:26-1:37 in video). Page 1 from Fernández-Miranda JC et al, Three-Dimensio-nal Microsurgical and Tractographic Anatomy of the White Matter of the Human Brain, Neurosurgery, 2008, Volume 62, issue suppl_3, SHC989-SHC1028, by permission of the Congress of Neurological Surgeons (1:54-1:56 in video).

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Microsurgical Anatomy and Quantitative Analysis of the Transtemporal-Transchoroidal Fissure Approach to the Ambient Cistern

Operative Neurosurgery ◽

10.1227/01.neu.0000176407.35946.88 ◽

2005 ◽

Vol 57 (suppl_4) ◽

pp. ONS-228-ONS-235 ◽

Cited By ~ 6

Author(s):

Rungsak Siwanuwatn ◽

Pushpa Deshmukh ◽

Joseph M. Zabramski ◽

Mark C. Preul ◽

Robert F. Spetzler

Keyword(s):

Quantitative Analysis ◽

Temporal Lobe ◽

Cerebral Artery ◽

Posterior Cerebral Artery ◽

Vascular Anatomy ◽

Venous Drainage ◽

Preoperative Imaging ◽

Surgical Approaches ◽

Microsurgical Anatomy ◽

Ambient Cistern

Abstract OBJECTIVE: Surgical approaches to ambient cistern lesions are complex. We investigated the microanatomy of the transtemporal-transchoroidal fissure approach to the ambient cistern with emphasis on exposure of the posterior cerebral artery. METHODS: Dissections were performed bilaterally in five silicone-injected cadaveric heads. Critical anatomic distances, specifically with reference to the P2 segment of posterior cerebral artery in relation to the inferior choroidal point and P2–P3 junction, were measured with digital calipers. Other landmarks (temporal lobe tip, points from the temporal base to the choroidal fissure) were included for quantitative analysis. RESULTS: The transtemporal-transchoroidal fissure approach provided adequate exposure of the ambient cistern, minimized temporal lobe retraction, and allowed assessment of regional microanatomy. The mean distance from the temporal base to the choroidal fissure measured 18.09 mm (range, 16.9–21.9 mm). The distances from the choroidal fissure to P2 varied at the coronal plane of the inferior choroidal point (mean, 6.96 mm; range, 3.6–12.0 mm) and the P2–P3 junction (mean, 6.02 mm; range, 4.3–6.9 mm), respectively. CONCLUSION: The transtemporal-transchoroidal fissure approach provides a corridor to the ambient cistern and P2–P3 junction while minimizing temporal lobe retraction and avoiding interruption of temporal lobe venous drainage. Because of widely variable vascular anatomy, access to posterior cerebral artery lesions using this approach requires preoperative imaging to identify the specific location of the P2–P3 junction.

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Surgical Anatomy of Endoscope-Assisted Approaches to Common Aneurysm Sites

Operative Neurosurgery ◽

10.1227/neu.0000000000000205 ◽

2013 ◽

Vol 10 (1) ◽

pp. 121-144 ◽

Cited By ~ 4

Author(s):

Maria Peris-Celda ◽

Leila Da Roz ◽

Alejandro Monroy-Sosa ◽

Takashi Morishita ◽

Albert L. Rhoton

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Optic Tract ◽

Small Diameter ◽

Vascular Anatomy ◽

Surgical Anatomy ◽

Microsurgical Anatomy ◽

Endoscopy Training ◽

Endoscopic View ◽

Endoscopic Assistance

Abstract BACKGROUND: The endoscope is being introduced as an adjuvant to improve visualization of certain areas in open cranial surgery. OBJECTIVE: To describe the endoscopic anatomy of common aneurysm sites and to compare it with the microsurgical anatomy. METHODS: Pterional, anterior interhemispheric, and subtemporal approaches to the most common aneurysm sites were examined in cadaveric heads under the surgical microscope and with the endoscope. RESULTS: The endoscopic view, particularly with the angled endoscopes, provides a significant improvement compared with the microscopic view, especially for poorly visualized sites such as the medial aspect of the supraclinoid carotid artery and its branches, the area below the anterior perforated substance and optic tract, and the carotid and basilar bifurcations. The endoscope aided in the early visualization of perforating branches at each aneurysm site except the middle cerebral artery. Small-diameter optics (2.7 mm) provided greater space for dissection and less potential for tissue damage in narrow places, whereas the larger 4-mm diameter optics provided better visualization and less panoramic distortion. The positioning of the endoscope for each aneurysm site is reviewed. CONCLUSION: The endoscope provides views that complement or improve the microscopic view at each aneurysm site except the middle cerebral artery. Endoscopy training and a thorough knowledge of endoscopic vascular anatomy are essential to safely introduce endoscopic assistance in vascular surgery.

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Is there an amodal “semantic” area in the left posterior temporal lobe?

10.31219/osf.io/2dczh ◽

2018 ◽

Author(s):

Feng Rong ◽

Jiang Xu ◽

Karen Emmorey ◽

Allen R. Braun ◽

Gregory Hickok

Keyword(s):

Temporal Lobe ◽

Sensory Modality ◽

Region Of Interest ◽

Temporal Region ◽

Left Posterior ◽

High Level ◽

Mri Study ◽

Multivariate Pattern ◽

Open Question ◽

Univariate Analyses

Portions of the left posterior temporal lobe are widely believed to comprise a “convergence zone” for integrating information from various sensory modalities and therefore for accessing high-level semantic information. It is an open question whether the network in this posterior temporal lobe region is coding/processing abstract, amodal information or whether neural codes retain sensory modality-tied representations. A recent functional MRI study (Xu et al. 2009, PNAS, 106, 20664-20669) seems to support the amodal account: using standard univariate general linear model (GLM) analyses, the left posterior temporal lobe region was equally activated during the processing of visually presented meaningful symbolic hand gestures and auditorily presented spoken glosses of those same gestures, relative to meaningless control gestures/speech, thus showing no preferential response according to modality of presentation of the same information. However, standard univariate analyses may not be sensitive to the micro-organization of the region of interest. In the present study we reanalyzed the same dataset using a region of interest (ROI)-based multivariate pattern classification method to assess modality sensitivity in the posterior temporal lobe ROI. We found that the pattern of activity in the ROI significantly discriminated between the visual and auditory conditions, including the meaningless control conditions. Moreover, mapping of the prediction coefficients onto the voxels within the ROI demonstrated a gradient of preference among modalities, where the gesture preferring voxels were distributed more medial and posterior, and the speech preferring voxels were distributed more lateral and anterior. These findings suggest that the left posterior temporal region is not coding information in an amodal format, at least broadly, but contains sub-regions that are sensitive to each individual modality.

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Microsurgical anatomy of the anterior approach to the mesial temporal region

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0038-1625664 ◽

2012 ◽

Vol 31 (02) ◽

pp. 81-85

Author(s):

Eberval Gadelha Figueiredo ◽

Manoel Jacobsen Teixeira

Keyword(s):

Temporal Lobe ◽

Cerebral Peduncle ◽

Temporal Region ◽

Microsurgical Anatomy ◽

Range Of Movement ◽

Area Of Interest ◽

Mesial Temporal Lobe ◽

Subfrontal Approach ◽

Orbital Rim ◽

Sphenoid Ridge

AbstractAnterior approaches to the mesial temporal lobe are favored by its anatomy limited medially by the cerebral peduncle and laterally by the lateral temporal lobe. We have routinely used an anterior subfrontal approach to operate on mesial temporal lesions. In this paper, we describe its microsurgical anatomy and detail its clinical application. Surgical positioning, removal of the orbital rim, and drilling the sphenoid ridge are the main principles of this technique. Adequate positioning is crucial to displace the temporal lobe from the middle fossa to improve exposure. Removing the orbital rim ensures an ample range of movement for the surgical microscope, augments visualization, and improves surgical versatility. Finally, drilling the sphenoid ridge amplifies exposure near the area of interest, permitting increased visualization and manipulation.

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Cavernomas and Arteriovenous Malformations in the Mesial Temporal Region: Microsurgical Anatomy and Approaches

Operative Neurosurgery ◽

10.1227/neu.0000000000001239 ◽

2016 ◽

Vol 13 (1) ◽

pp. 113-123 ◽

Cited By ~ 1

Author(s):

Alvaro Campero ◽

Pablo Ajler ◽

Carlos Rica ◽

Albert Rhoton

Keyword(s):

Arteriovenous Malformations ◽

Temporal Lobectomy ◽

Temporal Region ◽

Microsurgical Anatomy ◽

Anterior Portion ◽

Anterior Temporal Lobectomy ◽

Posterior Portion ◽

Transinsular Approach ◽

Posterior Sector ◽

Formalin Fixed

Abstract BACKGROUND: The mesial temporal region (MTR) is located deep in the temporal lobe and it is surrounded by important vascular and nervous structures that should be preserved during surgery. OBJECTIVE: To describe microsurgical anatomy and approaches to the MTR in relation to cavernomas and arteriovenous malformations (AVMs). METHODS: Five formalin-fixed and red silicone-embedded heads of adult cadavers were used for this study. Between January 2003 and June 2014, 7 patients with cavernomas and 6 patients with AVMs in the MTR underwent surgery. RESULTS: The MTR of the cadavers was divided into 3 areas: anterior, middle, and posterior. Of the 7 patients with MTR cavernomas, 4 were located anteriorly, 2 were located medially, and 1 was located posteriorly. Of the 6 patients with MTR AVMs, 3 were located in the anterior sector, 2 in the middle sector, and 1 in the posterior sector. For the anterior portion of the MTR, a transsylvian-transinsular approach was used; for the middle portion of the MTR, a transtemporal approach was used (anterior temporal lobectomy); and for the posterior portion of the MTR, a supracerebellar-transtentorial approach was used. CONCLUSION: Dividing the MTR into 3 regions allows us to adapt the approach to lesion location. Thus, the anterior sector can be approached via the sylvian fissure, the middle sector can be approached transtemporally, and the posterior sector can be approached via the supracerebellar approach.

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Microsurgical Anatomy of the Anterior Circulation of the Brain Adjusted to the Neurosurgeon’s Daily Practice

Brain Sciences ◽

10.3390/brainsci11040519 ◽

2021 ◽

Vol 11 (4) ◽

pp. 519

Author(s):

Tomas Poblete ◽

Daniel Casanova ◽

Miguel Soto ◽

Alvaro Campero ◽

Jorge Mura

Keyword(s):

Daily Practice ◽

Computed Tomographic Angiography ◽

Poor Quality ◽

Surgical Anatomy ◽

Microsurgical Anatomy ◽

Anterior Circulation ◽

Computed Tomographic ◽

Intrinsic Complexity ◽

Tomographic Angiography

The study of cerebrovascular anatomy can be difficult and may take time due to its intrinsic complexity. However, it can also be difficult for the following reasons: the excessive description of neuroanatomy making articles hard to read, the unclear clinical application of what is written, the use of simplified or intricate schematic drawings that are not always appropriate for effective teaching, the poor quality of neuroanatomy dissections and the use of unusual views of figures that are not strictly related to the most frequent neuroimages to be interpreted in daily practice. Because of this, we designed an article that incorporates original and accurate anatomical dissections in an attempt to improve its comprehensibility. Five formalin-fixed adult cadaveric heads, whose vessels were injected with a colored silicone mixture (red for arteries and blue for veins), were dissected and examined under a microscope with magnifications from 3× to 40×. Special emphasis has been placed on correlating topographic anatomy with routine neuroimaging studies from computed tomographic angiography (CTA) and digital subtraction angiography (DSA). The essential surgical anatomy in a neurosurgeon’s daily practice is also described. The cadaveric dissections included in this study contribute to the understanding of the cerebrovascular anatomy necessary for the neurosurgeon’s daily practice.

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New Perspectives on the Surgical Anatomy and Nomenclature of the Temporal Region

Plastic & Reconstructive Surgery ◽

10.1097/prs.0b013e31829ad44e ◽

2013 ◽

Vol 132 (3) ◽

pp. 461e-463e ◽

Cited By ~ 10

Author(s):

Justin X. O’Brien ◽

Mark W. Ashton ◽

Warren M. Rozen ◽

Richard Ross ◽

Bryan C. Mendelson

Keyword(s):

Surgical Anatomy ◽

Temporal Region

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Left posterior temporal cortex is sensitive to syntax within conceptually matched Arabic expressions

Scientific Reports ◽

10.1038/s41598-021-86474-x ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Suhail Matar ◽

Julien Dirani ◽

Alec Marantz ◽

Liina Pylkkänen

Keyword(s):

Temporal Lobe ◽

Temporal Cortex ◽

Syntactic Complexity ◽

Conceptual Combination ◽

Single Word ◽

Grammatical Structure ◽

Neural Basis ◽

Word Meanings ◽

Left Posterior ◽

Vary Structure

AbstractDuring language comprehension, the brain processes not only word meanings, but also the grammatical structure—the “syntax”—that strings words into phrases and sentences. Yet the neural basis of syntax remains contentious, partly due to the elusiveness of experimental designs that vary structure independently of meaning-related variables. Here, we exploit Arabic’s grammatical properties, which enable such a design. We collected magnetoencephalography (MEG) data while participants read the same noun-adjective expressions with zero, one, or two contiguously-written definite articles (e.g., ‘chair purple’; ‘the-chair purple’; ‘the-chair the-purple’), representing equivalent concepts, but with different levels of syntactic complexity (respectively, indefinite phrases: ‘a purple chair’; sentences: ‘The chair is purple.’; definite phrases: ‘the purple chair’). We expected regions processing syntax to respond differently to simple versus complex structures. Single-word controls (‘chair’/‘purple’) addressed definiteness-based accounts. In noun-adjective expressions, syntactic complexity only modulated activity in the left posterior temporal lobe (LPTL), ~ 300 ms after each word’s onset: indefinite phrases induced more MEG-measured positive activity. The effects disappeared in single-word tokens, ruling out non-syntactic interpretations. In contrast, left anterior temporal lobe (LATL) activation was driven by meaning. Overall, the results support models implicating the LPTL in structure building and the LATL in early stages of conceptual combination.

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