Microsurgical anatomy of the central lobe

The microsurgical anatomy of the paracentral lobule artery: a cadaveric series

PURPOSE

The paracentral lobule artery (PLA) is a typically present branch of the distal anterior cerebral artery (ACA), irrigating the homonymous lobule. The PLA origin is either a pericallosal portion of the ACA or a prominent branch of the ACA termed callosomarginal (CMA). In addition to the paracentral lobule, the PLA irrigates the cingulate gyrus in the medial hemispheric surface, and the superior portion of the precentral and postcentral gyri in the lateral hemispheric surface. The present cadaveric case series aimed at establishing previously unreported morphometric estimates of the PLA, including its length according to its site of origin, its supplying branches according to its distribution area, as well as its anastomoses.

METHODS

Seventeen colored latex-injected cadaveric heads were studied with a surgical microscope and microsurgical instruments.

RESULTS

The PLA was invariably present and most commonly originated from the A4 (n = 15 hemispheres, 50%) segment of the ACA. Other PLA origins were the CMA (n = 10, 30%), the A3 (n = 5, 16.7%) and the A5 (n = 1, 3.3%) segments. When the PLA originated from the A4, its mean (SD) overall length was 7.6 (17.9) mm and its mean (SD) diameter was 0.88 (0.26) mm. The PLA supplied the paracentral lobule, cingulate gyrus and post central gyrus with a mean (SD) of 28.07 (13.4), 8.53 (4.27), 5.92 (4.4) branches respectively and the precentral gyrus with a median [IQR] of 2 [0-6] branches. The most common anastomoses of the PLA in the medial and the lateral hemispheric surface involved the ipsilateral posterior internal frontal artery and the branches of the middle cerebral artery, respectively. There were no significant differences between sexes or hemispheric sides for the anatomical features of the artery analyzed.

CONCLUSION

The present study established previously unreported morphometric estimates for the PLA by considering all possible PLA variant origins and morphological variants. Given that variable pathologies have been previously detected in the areas supplied by the PLA, a better understanding of its anatomy can aid surgical planning and approaches.

The Fork sign: a new cortical landmark in the human brain

In the cerebral cortex, establishing the precise relationship between functional areas and the macroscopic anatomy of gyri and sulci has a paramount importance for the field of neuroimaging and neurosurgical interventions. The anatomical orientation should start with the identification of anatomical landmarks to set the anatomo-functional boundaries. The human central sulcus region stands out as a well-defined structural and functional unit housing the primary motor and sensory cortices and is considered as key region to be identified during brain surgery. While useful anatomical landmarks have been discovered, especially in the axial plane, the identification of this region in the sagittal plane remains sometimes difficult. Using cadaveric whole brains and multi-modal analysis of MRI brain scans, we systematically observed a tuning fork-shaped sulco-gyral configuration centred around the gyral continuum bridging the pre-central gyrus with the middle frontal gyrus. We provide evidence that this 'Fork sign' is a consistent morphological feature visible on the lateral surface of the brain and a reliable radioanatomical landmark for identifying central sulcus region structures on sagittal MRI images, including the motor hand area.

Tactile stimulation designs adapted to clinical settings result in reliable fMRI-based somatosensory digit maps

Movement constraints in stroke survivors are often accompanied by additional impairments in related somatosensory perception. A complex interplay between the primary somatosensory and motor cortices is essential for adequate and precise movements. This necessitates investigating the role of the primary somatosensory cortex in movement deficits of stroke survivors. The first step towards this goal could be a fast and reliable functional Magnetic Resonance Imaging (fMRI)-based mapping of the somatosensory cortex applicable for clinical settings. Here, we compare two 3 T fMRI-based somatosensory digit mapping techniques adapted for clinical usage in seven neurotypical volunteers and two sessions, to assess their validity and retest-reliability. Both, the traveling wave and the blocked design approach resulted in complete digit maps in both sessions of all participants, showing the expected layout. Similarly, no evidence for differences in the volume of activation, nor the activation overlap between neighboring activations could be detected, indicating the general feasibility of the clinical adaptation and their validity. Retest-reliability, indicated by the Dice coefficient, exhibited reasonable values for the spatial correspondence of single digit activations across sessions, but low values for the spatial correspondence of the area of overlap between neighboring digits across sessions. Parameters describing the location of the single digit activations exhibited very high correlations across sessions, while activation volume and overlap only exhibited medium to low correlations. The feasibility and high retest-reliabilities for the parameters describing the location of the single digit activations are promising concerning the implementation into a clinical context to supplement diagnosis and treatment stratification in upper limb stroke patients.

Neurosustainability

While the human brain has evolved extraordinary abilities to dominate nature, modern living has paradoxically trapped it in a contemporary "cage" that stifles neuroplasticity. Within this modern environment lurk unseen natural laws with power to sustain the human brain's adaptive capacities - if consciously orchestrated into the environments we design. For too long our contemporary environments have imposed an unyielding static state, while still neglecting the brain's constant adaptive nature as it evolves to dominate the natural world with increasing sophistication. The theory introduced in this article aims to go back in nature without having to go back in time, introducing and expounding Neurosustainability as a novel paradigm seeing beyond the contemporary confines to architect environments and brains in parallel. Its integrated neuro-evidenced framework proposes four enrichment scopes-spatial, natural, aesthetic, and social-each holding multifaceted attributes promising to sustain regions like the hippocampus, cortex and amygdala. Neurosustainability aims to liberate the quintessential essence of nature to sustain and enhance neuroplastic processes through a cycle that begins with design and extends through epigenetic changes. This paradigm shift aims to foster cognitive health and wellness by addressing issues like stress, depression, anxiety and cognitive decline common in the contemporary era thereby offering a path toward a more neurosustainable era aiming to nurture the evolution of the human brain now and beyond.

Intravenous Thrombolysis Improved Aphemia and Confirmed the Dominant Precentral Gyrus as the Responsible Lesion

Aphemia is now considered an impairment of speech production. We present a case of an 89-year-old right-handed woman who received intravenous thrombolysis with a recombinant tissue plasminogen activator for the ischemic symptom "loss of speech" and recovered with an ischemic lesion of the left precentral gyrus. The patient had untreated atrial fibrillation. Neurological examination showed that her level of consciousness was alert, with normal comprehension and mild lower facial droop. Head computed tomography (CT) did not reveal a hemorrhagic lesion. To treat the acute ischemic stroke, she received a recombinant tissue plasminogen activator. Just after thrombolysis, she started to speak. Then, magnetic resonance imaging (MRI) revealed an acute ischemic infarction in the dominant precentral gyrus. Follow-up MRI revealed the peripheral middle cerebral artery territory infarction in the left precentral gyrus, but she still could speak. The symptom of "loss of speech" was considered aphemia. By intravenous thrombolysis, impaired speech production in our patient was believed to be caused by an infarction in the dominant precentral gyrus. This case also demonstrated that the rare clinical symptom was due to an ischemic stroke in the territory of the distal middle cerebral artery. Clinicians who engage in stroke care need to know the rare symptoms of aphemia in the era when mechanical thrombectomy could be considered a promising treatment option for distal medium vessel occlusion.

Awake craniotomy removal of a corticospinal tract developmental venous anomaly hemorrhage: A case report

Developmental venous anomalies (DVAs) are composed of mature venous vessels that lack malformed or neoplastic elements. Although the hemorrhage risk is considered negligible, some patients may have neurological symptoms attributable to acute infarction or intracranial hemorrhage secondary to thrombosis, in the absence of a coexisting cavernous malformation. We report the case of a 42-year-old patient who presented with acute left-hand paresis secondary to a subcortical hemorrhage. This bleeding originated from a DVA in the corticospinal tract area and was surgically drained through an awake craniotomy. To accomplish this, we used a trans-precentral sulcus approach. After the complete removal of the coagulum, small venous channels appeared, which were coagulated. No associated cavernoma was found. Although the main DVA trunk was left patent, no signs of ischemia or venous infarction were observed after coagulating the small venous channels found inside the hematoma cavity. Two weeks after the procedure, the patient's hand function improved, and he was able to resume desktop work. DVA-associated hemorrhage within the cortico-spinal tract could be safely removed with modern awake mapping techniques. This technique allowed the patient to rapidly improve his hand function.

Maximal safe resection of diffuse lower grade gliomas primarily within central lobe using cortical/subcortical direct electrical stimulation under awake craniotomy

Background

Diffuse lower-grade glioma (DLGG) in the central lobe is a challenge for safe resection procedures. To improve the extent of resection and reduce the risk of postoperative neurological deficits, we performed an awake craniotomy with cortical-subcortical direct electrical stimulation (DES) mapping for patients with DLGG located primarily within the central lobe. We investigated the outcomes of cortical-subcortical brain mapping using DES in an awake craniotomy for central lobe DLGG resection.

Methods

We performed a retrospective analysis of clinical data of a cohort of consecutively treated patients from February 2017 to August 2021 with diffuse lower-grade gliomas located primarily within the central lobe. All patients underwent awake craniotomy with DES for cortical and subcortical mapping of eloquent brain areas, neuronavigation, and/or ultrasound to identify tumor location. Tumors were removed according to functional boundaries. Maximum safe tumor resection was the surgical objective for all patients.

Results

Thirteen patients underwent 15 awake craniotomies with intraoperative mapping of eloquent cortices and subcortical fibers using DES. Maximum safe tumor resection was achieved according to functional boundaries in all patients. The pre-operative tumor volumes ranged from 4.3 cm³ to 137.3 cm³ (median 19.2 cm³). The mean extent of tumor resection was 94.6%, with eight cases (53.3%) achieving total resection, four (26.7%) subtotal and three (20.0%) partial. The mean tumor residue was 1.2 cm³. All patients experienced early postoperative neurological deficits or worsening conditions. Three patients (20.0%) experienced late postoperative neurological deficits at the 3-month follow-up, including one moderate and two mild neurological deficits. None of the patients experienced late onset severe neurological impairments post-operatively. Ten patients with 12 tumor resections (80.0%) had resumed activities of daily living at the 3-month follow-up. Among 14 patients with pre-operative epilepsy, 12 (85.7%) were seizure-free after treatment with antiepileptic drugs 7 days after surgery up to the last follow-up.

Conclusions

DLGG located primarily in the central lobe deemed inoperable can be safely resected using awake craniotomy with intraoperative DES without severe permanent neurological sequelae. Patients experienced an improved quality of life in terms of seizure control.

Cortical and white matter anatomy relevant for the lateral and superior approaches to resect intraaxial lesions within the frontal lobe

Despite being associated with high-order neurocognitive functions, the frontal lobe plays an important role in core neurological functions, such as motor and language functions. The aim of this study was to present a neurosurgical perspective of the cortical and subcortical anatomy of the frontal lobe in terms of surgical treatment of intraaxial frontal lobe lesions. We also discuss the results of direct brain mapping when awake craniotomy is performed. Ten adult cerebral hemispheres were prepared for white matter dissection according to the Klingler technique. Intraaxial frontal lobe lesions are approached with a superior or lateral trajectory during awake conditions. The highly eloquent cortex within the frontal lobe is identified within the inferior frontal gyrus (IFG) and precentral gyrus. The trajectory of the approach is mainly related to the position of the lesion in relation to the arcuate fascicle/superior longitudinal fascicle complex and ventricular system. Knowledge of the cortical and subcortical anatomy and its function within the frontal lobe is essential for preoperative planning and predicting the risk of immediate and long-term postoperative deficits. This allows surgeons to properly set the extent of the resection and type of approach during preoperative planning.

Surgery for Epilepsy Involving Rolandic and Perirolandic Cortex: A Case Series Assessing Complications and Efficacy

BACKGROUND

Surgical removal of lesions around the rolandic cortex remains a challenge for neurosurgeons owing to the high risk of neurological deficits. Evaluating the risk factors associated with motor deficits after surgery in this region may help reduce the occurrence of motor deficits.

OBJECTIVE

To report our surgical experience in treating epileptic lesions involving the rolandic and perirolandic cortices.

METHODS

We performed a single-center retrospective review of patients undergoing epilepsy surgeries with lesions located in the rolandic and perirolandic cortices. Patients with detailed follow-up information were included. The lesion locations, resected regions, and invasive exploration techniques were studied to assess their relationship with postoperative motor deficits.

RESULTS

Forty-one patients were included. Twenty-three patients suffered from a transient motor deficit, and 2 had permanent disabilities after surgery. Six patients with lesions at the posterior bank of the precentral sulcus underwent resection, and 5 experienced short-term motor deficits. Two patients with lesions adjacent to the anterior part of the precentral gyrus, in whom the adjacent precentral gyrus was removed, experienced permanent motor deficits. Lesions located at the bottom of the central sulcus and invading the anterior bank of the central sulcus were observed in 3 patients. The patients did not experience permanent motor deficits after surgery.

CONCLUSION

The anterior bank of the central sulcus is indispensable for motor function, and destruction of this region would inevitably cause motor deficits. The anterior bank of the precentral gyrus can also be removed without motor impairment if there is a preexisting epileptogenic lesion.

Motor outcome after resective surgery for the central lobe gliomas

Background:

Extent of resection (EOR) plays a major role in the prognosis on patients with gliomas, although the postoperative functionality of the patient is of great importance as well. It is why many surgeons advocate to not operate extensively on tumors that involve eloquent regions such as the central lobe. Recent series have demonstrated that it is possible to achieve extensive resections in this area without significantly affecting the functional outcome for these patients. We illustrate this issue with the experience obtained at the National Institute of Neurology and Neurosurgery in Mexico City.

Methods:

This is an observational and retrospective study that included patients that received surgical resection for intracranial gliomas that involved the central lobe at the National Institute of Neurology and Neurosurgery of Mexico, between January 2017 and May 2020. Demographic and clinical variables of the patients at the time of diagnosis were collected as well as tumor morphological variables, surgical adjuncts, and clinical outcomes. Statistical analysis was performed with SPSS software.

Results:

A total of 28 patients were included in the study with 43% of patients having a motor deficit before surgery. The average EOR was 88.6%. Patients presented with worsening of their motor status in the immediate postoperative period in 21% of the cases, although most of the patients recovered within the 1^st month of follow-up. After analyzing all variables, not having a presurgical motor deficit was a statistically significant risk factor for developing a new motor deficit in the immediate postoperative period (P: 0.02).

Conclusion:

A resective surgery for gliomas near or within the central lobe can be performed safely and a satisfactory motor outcome for patients can be achieved without sacrificing the EOR. An intact presurgical motor status is a risk factor for developing a new deficit after surgery.

Rolandic Cortex Morphology: Magnetic Resonance Imaging-Based Three-Dimensional Cerebral Reconstruction Study and Intraoperative Usefulness

Background  During brain surgery, the neurosurgeon must be able to identify and avoid injury to the Rolandic cortex. However, when only a small part of the cortex is exposed, it may be difficult to identify the Rolandic cortex with certainty. Despite various advanced methods to identify it, visual recognition remains an important backup for neurosurgeons. The aim of the study was to find any specific morphology pattern that may help to identify the Rolandic cortex intraoperatively.

Materials and Methods  Magnetic resonance imaging of the brain from patients with various conditions was used to create the three-dimensional cerebral reconstruction images. A total of 216 patients with 371 intact hemispheres were included. Each image was inspected to note the morphology of the Rolandic cortex and the suprasylvian cortex. Additionally, other two evaluators exclusively inspected the morphology of the suprasylvian cortex. Their observation results were compared to find the agreements.

Results  Several distinctive morphology patterns have been identified at the Rolandic cortex and the suprasylvian cortex including a genu, or a knob at the upper precentral gyrus, an angulation of the lower postcentral gyrus, a strip for pars opercularis, a rectangle for the lower precentral gyrus, and a triangle for the lower postcentral gyrus. Combined total and partial agreement of the suprasylvian cortex morphology pattern ranged from 60.4 to 85.2%.

Conclusion  The authors have demonstrated the distinctive morphology of the Rolandic cortex and the suprasylvian cortex. This information can provide visual guidance to identify the Rolandic cortex particularly during surgery with limited exposure.

Anterior Cerebral Artery Stroke: Role of Collateral Systems on Infarct Topography

[Figure: see text].

The supplementary motor area syndrome: a neurosurgical review

The supplementary motor area (SMA) syndrome is a frequently encountered clinical phenomenon associated with surgery of the dorsomedial prefrontal lobe. The region has a known motor sequencing function and the dominant pre-SMA specifically is associated with more complex language functions; the SMA is furthermore incorporated in the negative motor network. The SMA has a rich interconnectivity with other cortical regions and subcortical structures using the frontal aslant tract (FAT) and the frontostriatal tract (FST). The development of the SMA syndrome is positively correlated with the extent of resection of the SMA region, especially its medial side. This may be due to interruption of the nearby callosal association fibres as the contralateral SMA has a particular important function in brain plasticity after SMA surgery. The syndrome is characterized by a profound decrease in interhemispheric connectivity of the motor network hubs. Clinical improvement is related to increasing connectivity between the contralateral SMA region and the ipsilateral motor hubs. Overall, most patients know a full recovery of the SMA syndrome, however a minority of patients might continue to suffer from mild motor and speech dysfunction. Rarely, no recovery of neurological function after SMA region resection is reported.

Control of drop attacks with selective posterior callosotomy: Anatomical and prognostic data

OBJECTIVE

In a previous proof of concept study, selective posterior callosotomy achieved similar degree of control of drop attacks as total callosotomy, while sparing prefrontal interconnectivity. The present study aims to confirm this finding in a larger cohort and to provide anatomical and prognostic data.

METHODS

Fifty-one patients with refractory drop attacks had selective posterior callosotomy and prospective follow up for a mean of 6.4 years. Twenty-seven patients had post-operative magnetic resonance imaging (MRI) and 18 had tractography (DTI) of remaining callosal fibers. Pre and postoperative falls were quantified and correlated with demographic, clinical and imaging data.

RESULTS

Mean monthly frequency of drop attacks had a 95 % reduction, from 297 before to 16 after the procedure. Forty- one patients (80 %) had either complete or greater than 90 % control of the epileptic falls. Age and duration of epilepsy at surgery correlated with outcome (p values, respectively, 0.042 and 0.005). Mean index of callosal section along the posterior-to-anterior axis was 53.5 %. Extending the posterior section anterior to the midbody of the corpus callosum did not correlate with seizure control (p 0.91), providing fibers interconnecting the primary motor (M1) and caudal supplementary motor areas (SMA) were sectioned. Only one patient had a notable surgical complication which resolved in two days.

CONCLUSIONS

This level III cohort study with objective outcome assessment confirms that selective posterior callosotomy is safe and effective to control epileptic falls. Younger patients with smaller duration of epilepsy have better results. A posterior section contemplating the splenium, isthmus and posterior half of the body (posterior midbody) seems sufficient to achieve complete or almost complete control of drop attacks.

Surgical Management of Brain Metastases in the Perirolandic Region

Brain metastases (BM) are the most frequent intracranial tumors, which may result in significant morbidity and mortality when the lesions involve the perirolandic region. Surgical intervention for BM in the perirolandic region is still under discussion even though prompt relief of mass effect and avoidance of necrosis together with brain edema may not be achieved by radiotherapy. More recently, several researchers attempt to evaluate the benefit of surgery for BM within this pivotal sensorimotor area. Nevertheless, data are sparse and optimal treatment paradigm is not yet widely described. Since the advance in intraoperative neuroimaging and neurophysiology, resection of BM in the perirolandic region has been proven to be safe and efficacious, sparing this eloquent area while retaining reasonably low morbidity rates. Although management of BM becomes much more tailored and multimodal, surgery remains the cornerstone and principles of resection as well as indications for surgery should be well defined. This is the first review concerning the characteristics of BM involving the perirolandic region and the current impact of surgical therapy for the lesions. Future perspectives of advanced neurosurgical techniques are also presented.

Endoscopic management of an intrasellar arachnoid cyst through the tuber cinereum in an adult: a case report

The transventricular endoscopic approach is an effective less invasive method for the management of symptomatic intrasellar arachnoid cysts in adults. The open area of the brain tissue defect in the infundibular recess caused by the upward compression of the cyst is a common target site for fenestration from the third ventricle. This report highlighted an alternative approach through the tuber cinereum (denoted as "trans-tuberal"), which enabled the treatment of symptomatic cases with a small opening for cyst fenestration in the infundibular recess.

Indirect Structural Connectivity Identifies Changes in Brain Networks After Stroke

Background/Purpose: The purpose of this study was (1) to identify changes in structural connectivity after stroke and (2) to relate changes in indirect connectivity to post-stroke impairment. Methods: A novel measure of indirect connectivity was implemented to assess the impact of stroke on brain connectivity. Probabilistic tractography was performed on 13 chronic stroke and 16 control participants to estimate connectivity between gray matter (GM) regions. The Fugl-Meyer assessment of motor impairment was measured for stroke participants. Network measures of direct and indirect connectivity were calculated, and these measures were linearly combined with measures of white matter integrity to predict motor impairment. Results: We found significantly reduced indirect connectivity in the frontal and parietal lobes, ipsilesional subcortical regions, and bilateral cerebellum after stroke. When added to the regression analysis, the volume of GM with reduced indirect connectivity significantly improved the correlation between image parameters and upper extremity motor impairment (R² = 0.71, p < 0.05). Conclusion: This study provides evidence of changes in indirect connectivity in regions remote from the lesion, particularly in the cerebellum and regions in the fronto-parietal cortices, and these changes correlate with upper extremity motor impairment. These results highlight the value of using measures of indirect connectivity to identify the effect of stroke on brain networks. Impact statement Changes in indirect structural connectivity occur in regions distant from a lesion after stroke, highlighting the impact that stroke has on brain functional networks. Specifically, losses in indirect structural connectivity occur in hubs with high centrality, including the fronto-parietal cortices and cerebellum. These losses in indirect connectivity more accurately reflect motor impairments than measures of direct structural connectivity. As a consequence, indirect structural connectivity appears to be important to recovery after stroke and imaging biomarkers that incorporate indirect structural connectivity might improve prognostication of stroke outcomes.

Safe and accurate sylvian dissection with the use of indocyanine green videoangiography

Background:

Sylvian dissection is an essential microneurosurgical skill for neurosurgeons. The safe and accurate opening of the sylvian fissure is desirable for a good prognosis.

Methods:

The aim of this report is to demonstrate the use of indocyanine green (ICG) videoangiography to recognize the superficial sylvian vein (SSV) and thus enable a wide opening of the sylvian fissure, especially in patients with subarachnoid hemorrhage (SAH).

Results:

The small tributary flowing into the SSV was distinguishable from a passing one, which deeply entered the insula. In addition, an entering point of a tributary to the SSV, which ran perpendicular to the insula, was occasionally determined. SSV, which was barely discernable in a reddish SAH involving the sylvian fissure, was clearly demarcated using ICG videoangiography. Two representative cases of sylvian dissection are herein presented.

Conclusion:

The performance of ICG videoangiography before sylvian dissection is a simple and useful method for identifying a vital approach route for safe and accurate sylvian dissection, and it reduces the risk of causing any accidental injury to the veins in the sylvian fissure.