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Microsurgical Anatomy and Approaches to the Cerebral Central Original Article Microsurgical Anatomy and Approaches to the Cerebral Central Core Matias Baldoncini1,2, Alvaro Campero2,3, Julio Ce´ sar Pe´ rez Cruz4, Rodolfo Recalde5, Richard Parraga6,7, Federico J. Sanchez Gonzalez8,9, Martin Fortte10,11, Pablo Gonza´ lez Lo´ pez12 - OBJECTIVE: Through a cadaveric study, we divided the contralateral transcallosal approach, a choroidal trans- cerebral central core (CCC) into different areas and have fissure approach, a trans-splenial approach, transparietal proposed a corresponding neurosurgical approach for each access entering the intraparietal sulcus, and trans-sylvian sector. As a secondary objective, we analyzed the cortical approach. The preoperative imaging studies should be and subcortical microsurgical anatomy of the CCC. The CCC analyzed using our method to select the most accurate and includes the insula, extreme capsule, claustrum, external safe approach. capsule, lenticular nucleus, internal capsule, caudate nu- - CONCLUSIONS: We have provided a description of the cleus, and thalamus. limits and anatomy of the CCC using brain dissection, an - METHODS: Twelve adult human brain hemispheres and analysis of operated cases, and useful measurements for one cadaveric head specimen were dissected and studied the neurosurgeon. at the Laboratory of Neuroanatomic Microsurgical of the University of Buenos Aires. Nine cases of CCC neurosur- gical pathologies were included in the present study and analyzed. Digital drawings were created of the approaches proposed for each sector of the CCC showing the most INTRODUCTION relevant surgical details. Photographs of each dissection he cerebral central core (CCC) is a topographical area and measurements obtained were taken. located between the sylvian cistern laterally and the third - RESULTS: We divided the CCC into a medial, intermedi- T ventricle medially. It has been described as a block that ate, and lateral sector, with specific subdivisions for the rests over the midbrain. It includes the insular cortex, extreme lateral and medial sectors. The lateral projection of the capsule, claustrum, external capsule, lenticular nucleus, internal capsule, caudate nucleus, and thalamus. In addition, it is sur- foramen of Monro was found deep to the third short gyri of rounded by a group of short and long association commissural the insula with the following distances: anterior insular and projection fibers. This white substance, located between the limen margin, 23.95 mm; posterior insular limen margin, peri-insular and lateral ventricle grooves, is known as the cerebral 22.92 mm; superior limiting sulcus, 14.99 mm, and inferior isthmus.1 It connects the nucleus of the central core with the rest limiting sulcus, 13.76 mm. We have proposed the following of the hemisphere. It also anatomically separates the sylvian approaches: an ipsilateral transcallosal approach, a cistern from the ventricular system. As the topographic center of Key words Laboratory, Neurosurgical Division, Clinical Hospital, University of Buenos Aires, Buenos 6 - Cerebral central core Aires, Argentina; Department of Neurological Surgery, Hospital Univalle, Cochabamba- 7 8 - Microsurgery Cercado, Bolivia; Institute of Neurological Sciences, São Paulo, Brazil; Epilespy Surgery - Neurosurgical approaches Section, Neurosurgical Division, Clinical Hospital, University of Buenos Aires, Buenos Aires, 9 10 - Neuroanatomy Argentina; Neurosurgical Division, Clinic of Cuyo, Mendoza, Argentina; Division Neurosurgery, Interzonal Specialized Children’s Hospital, Mar del Plata, Argentina; 11 12 Abbreviations and Acronyms Belgrano Clinic and 25 de Mayo Clinic, Mar del Plata, Argentina; and Department of AC: Anterior commissure Neurosurgery, Hospital General of Alicante, Alicante, Spain CCC: Cerebral central core To whom correspondence should be addressed: Matias Baldoncini, M.D. LPFM: Lateral projection foramen of Monro [E-mail: [email protected]] Citation: World Neurosurg. (2019). From the 1Department of Neurological Surgery, San Fernando Hospital, Buenos Aires, https://doi.org/10.1016/j.wneu.2019.04.139 Argentina; 2Laboratory of Neuroanatomic Microsurgical, II Division of Anatomy, Medicine Journal homepage: www.journals.elsevier.com/world-neurosurgery School, University of Buenos Aires, Buenos Aires, Argentina; 3Department of Neurological Available online: www.sciencedirect.com Surgery, Padilla Hospital, Tucumán, Argentina; 4Anatomy Academy, Higher School of ª Medicine, Instituto Politécnico Nacional Neurosciences, Faculty of Medicine, Autonomous 1878-8750/$ - see front matter 2019 Elsevier Inc. All rights reserved. National University of Mexico, Mexico City, Mexico; 5Skull Base Section and Neuroanatomic WORLD NEUROSURGERY -: e1-e12, - 2019 www.journals.elsevier.com/world-neurosurgery e1 ORIGINAL ARTICLE MATIAS BALDONCINI ET AL. MICROSURGICAL ANATOMY AND APPROACHES TO CCC the brain, it integrates various types of sensitive, motor, cognitive, highlight the anatomy of the region and the microsurgical division and emotional information. A few investigators2-4 have recognized through the cranial approaches. the CCC as a different region in the brain and highlight the importance of surgical planning. From a strictly neurosurgical point of view, its differentiation will be useful, because it contains RESULTS eloquent structures of deep localization, with complex cisternal and ventricular relationships. Thus, we divided the CCC and Anatomy of CCC proposed different neurosurgical approaches for each sector for The lateral side of the CCC corresponds to the insular surface that the pathological entities located within this important anatomical is in the depth of the sylvian cistern when retracting the fronto- region. parietal and temporal operculum. The insular surface is sur- rounded by the circular groove composed of an anterior, superior, and inferior limiting sulcus. The circular sulcus is interrupted at METHODS the inferior anterior border of the insular surface by the insular The cortical and subcortical anatomy of the CCC was studied in 12 limen, which presents as a C-shape and has upper and lower 4,8-13 adult human cerebral hemispheres in the Laboratory of Micro- points. surgery Neuroanatomy of the II Division of Anatomy of the Uni- The upper point of the limen joins the anterior limiting sulcus 4 versity of Buenos Aires. Axial and coronal sections were taken in 2 in the frontal lobe, termed the frontal limen point by Ribas et al. cerebral hemispheres. Next, brain staining was performed using The lower point joins the lower limiting groove in the temporal 4 the Mulligan technique.5 The remaining hemispheres were fixed lobe and has been referred to as the “temporal limen point.” in 10% formaldehyde for 1 month and then frozen for 30 more The anterior limiting sulcus extends from the frontal limen days, following the guidelines of Ludwig and Klingler6 and of point to the point where it intersects with the upper limiting other investigators.7 It is through this technique that the sulcus, referred to as the anterior insular point, and coinciding on expansion of the water that exists between the cerebral the surface of the sylvian fissure with the anterior sylvian point. fascicules can form ice crystals, thus facilitating their dissection. The upper limiting groove continues toward the posterior edge of 4,9 We used a human head, previously injected with red and blue the insula, reaching the so-called posterior insular point, at silicone and fixed with aqueous solution of 10% diluted form- which it joins with the inferior limiting groove. The inferior aldehyde for 30 days. After performing the craniotomy, it was limiting sulcus extends from the posterior insular point to the frozen for 1 month, allowing for the combination of the color- temporal limen point. The medial aspect is limited inferiorly by ation of the central core vessels and dissection of the nuclei and the hypothalamic sulcus, anteriorly by the head of the caudate fascicles that constitute it. Using the technique proposed by nucleus, and superiorly by the body of the caudate nucleus, Ribas et al.,4 morphometric data were obtained from the 12 crossing on its trajectory the septal area, fornix, third ventricle, hemispheres, which had been transfixed with pins from the frontal horn, and body of the lateral ventricle. medial side through the foramen of Monro to analyze its The CCC anterior surface is an imaginary plane that extends projection on the insular surface. After obtaining the lateral from the anterior limiting sulcus, passes through the anterior edge projection of the foramen of Monro (LPFM), the distance from this point to the upper and lower limiting groove of the insula was measured. Finally, 2 coronal planes were drawn to delimit the anterior and posterior edge of the lenticular nucleus, termed the anterior and posterior lenticular margin, respectively. All measurements were obtained manually on each specimen using a digital caliper. Two magnification microscopes of 6Â,10Â and 40Â, blunt instruments, and diaeresis elements were used to perform the dissections, including curved and straight microsurgery scissors, straight micro-tweezers, Penfield model no. 7 straight and curved, and wooden and cerebral spatulas, straight and curved. The photographs were taken using a Nikon D7200 camera with a Micro Nikon 40mm F2.8 lens and annular flash (Nikon, Tokyo, Japan). This was configured using a variable diaphragm, with a shutter speed of 100, ISO 250, and ring flash 1/128. Finally, we have described the different strategies for the
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