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The Anterior Sylvian Point and the Suprasylvian Operculum

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The Anterior Sylvian Point and the Suprasylvian Operculum Neurosurg Focus 18 (6b):E2, 2005 The anterior sylvian point and the suprasylvian operculum GUILHERME CARVALHAL RIBAS, M.D., EDUARDO CARVALHAL RIBAS, AND CONSUELO JUNQUEIRA RODRIGUES, M.D. Clinical Anatomy Discipline of the Department of Surgery, University of São Paulo Medical School, Hospital Albert Einstein, São Paulo, Brazil Object. The sylvian fissure or lateral sulcus is the most identifiable feature of the superolateral brain surface and constitutes the main microneurosurgical corridor, given the high frequency of approachable intracranial lesions through this route. The anterior sylvian point (ASyP) divides this fissure in its main anterior and posterior rami and was evaluated in this study for its morphology, exact location, and sulcal and neural relationships to assess its suit- ability as an initial, visually identifiable landmark for further neuroimaging and intraoperative estimation of its adjoin- ing suprasylvian structures. Methods. This study is based on 32 formalin-fixed cerebral hemispheres. The brains were removed from the skulls of 16 cadavers after the introduction of plastic catheters through properly positioned burr holes; the number of speci- mens for some of the analyzed data differed because of incorrect positioning of catheters or damage to the studied structures caused by the initial steps of the study. The ASyP had a cisternal aspect in 94% of the specimens and was always located inferior to the triangular part of the inferior frontal gyrus, 2.3 Ϯ 0.5 cm in front of the inferior rolandic point. The ASyP was located underneath the 1.5-cm-diameter cranial area of the anterior aspect of the squamous suture. Its adjoining structures that compose the suprasylvian operculum have constant basic morphological configurations. Conclusions. The ASyP underlies the anterior aspect of squamous suture just behind the pterion, can be easily rec- ognized, and constitutes a reliable initial sulcal landmark for further estimation of the suprasylvian sulcal and gyral structures. The suprasylvian operculum can be understood as a series of convolutions roughly arranged as a V-shaped convolution, with its vertex constituted by the ASyP, followed by three U-shaped convolutions and one C-shaped con- volution. KEY WORDS • brain mapping • burr hole • cerebral cortex • prefrontal cortex • cranial suture • craniometry • craniotomy In their original description of the microsurgical anato- outer aspect of the hemisphere.” In his textbook published my of the subarachnoid cisterns in 1976, Ya¸sargil, et al.,32 in 1912, Krause10 reproduced illustrations of the German emphasized the importance of the SyF, which then became anatomist August von Froriep (1849–1917)11 with identifi- the main microneurosurgical corridor to the base of the cation of the sylvian point and also illustrated an anatomi- brain. In later publications Ya¸sargil, et al., described in de- cal opening of the SyF for the exposure of a superficial tail the microanatomy of this fissure and its underlying cis- insular lesion (Fig. 1). Recently Türe, et al.,27 stressed the tern29,30,33 and the technique of its opening. In agreement use of the term sylvian point. with other authors,12,14,16–18 Ya¸sargil divides the SyF into a Despite the emphasis given by recent authors to the loca- proximal segment (stem, sphenoidal, anterior ramus) and a tion of the sylvian point, none of them referred to the fre- quent enlargement of the fissure at the sylvian point, de- distal segment (lateral, posterior ramus) separated by the 12,14,16,27,29,30,33 sylvian point,27,33 which is located beneath the triangular spite its presence in their own illustrations. This cisternal aspect of the sylvian point is also evident in the part of the IFG. The horizontal and the anterior ascending 4,8,13,15,18–22 branches of the SyF that delineate the triangular part of the illustrations in many other recent publications and in old texts10,24,25 (Fig. 2). IFG arise at the sylvian point.14 23 The constant location and striking cisternal appearance Taylor and Haugton, in their study of the topography of of the sylvian point indicate that it can be used not only as the convolutions and fissures of the brain published in a starting site to open the SyF, but also intraoperatively as 1900, used the term sylvian point, defining it as “the point an initial landmark to identify other important neural and where the main stem of the fissure of Sylvius reaches the sulcal structures along the fissure that are usually hidden by Abbreviations used in this paper: ASqP = anterior squamous arachnoidal and vascular coverings. In this study the syl- point; ASyF = anterior sylvian fissure; ASyP = anterior sylvian vian point is designated as the anterior as opposed to the point; IFG = inferior frontal gyrus; IFS = inferior frontal sulcus; posterior one,26 which corresponds to the distal extremity of IRP = inferior rolandic point; SyF = sylvian fissure. the posterior ramus of the SyF, from which the ascending Neurosurg. Focus / Volume 18 / June, 2005 1 Unauthenticated | Downloaded 10/01/21 06:42 PM UTC G. C. Ribas, E. C. Ribas, and C. J. Rodrigues Fig. 1. Reproduction of an old illustration of the sylvian point by August von Froriep (A), and of the SyF opening by F. Krause (B). (Reprinted from Krause F: Chirurgie du Cerveau et de la Moelle Epiniere. Paris: Societé D’Editions Scientifiques et Medicales, 1912, Vols I and II.) terminal ramus and the occasional descending terminal This study was conducted in two parts: Part I was a study ramus originate.14 of the surface anatomy of the ASyP and of its related neur- Our aims in this study were as follows: 1) to evaluate and al and sulcal structures; and Part II was a study of the rela- confirm the aforementioned general features of the anterior tionships of the ASyP with its external cranial landmarks. sylvian point; 2) to evaluate and establish the main relation- After proper identification of the cadaver and with the path- ships of the ASyP with other important neural and sulcal ologist’s consent, the study was conducted according to the structures along the sylvian fissure; and 3) to establish the following steps: 1) exposure of the external cranial surface relationships of the ASyP with external cranial landmarks by the standard biauricular necroscopic incision and detach- to orient its surgical exposure. ment of both temporal muscles, with special attention paid to exposure of the cranial sutures in particular; 2) placement of a 1.5-cm burr hole at the anterior part of the squamous MATERIALS AND METHODS suture, just behind the sphenoparietal suture, with an elec- Data were collected from 32 cerebral hemispheres ob- trical drill (Dremel Moto-Tool; Dremel, Racine, WI); 3) tained in 16 adult cadavers at the Death Verification In- opening of the dura mater with a No. 11 blade scalpel; 4) stitute of the Department of Pathology and at the Clinical perpendicular introduction of an approximately 7-cm-long Anatomy Discipline of the Department of Surgery at the (2.5-mm-diameter) plastic tracheal aspiration tube (model University of São Paulo Medical School, after authoriza- sonda-suga No. 08; Embramed, São Paulo, Brazil) with the tion from the Ethical Committee for Analysis of Research aid of a metallic guide; 5) circumferential opening of the Projects. skull with the appropriate saw and of the dura mater with Fig. 2. Variations of the IFG illustrated by Testut and Jacob, showing the typical enlargement of the SyF beneath its triangular part. (Reprinted from Testut L, Jacob O: Tratado de Anatomia Topográfica, ed 5. Barcelona: Salvat, 1932.) 2 Neurosurg. Focus / Volume 18 / June, 2005 Unauthenticated | Downloaded 10/01/21 06:42 PM UTC The anterior sylvian point and the suprasylvian operculum scissors; 6) careful removal of the whole encephalon after basal divisions of the intracranial vessels and the cranial nerves; 7) replacement of the calvaria and closure of the scalp for necroscopic final procedures by the expert person- nel; 8) storage of the resected encephalons in 10% formalin solution, with the specimens suspended by a string tied to the basilar artery to avoid brain deformations; 9) after ade- quate fixation (at least 2 months), section of the brainstem at the midbrain and its removal together with the cerebel- lum; 10) removal of the arachnoidal membranes and the superficial vessels of the cerebral hemispheres with the aid of microsurgical loupes (3.5ϫ; Designs for Vision, Inc., Ronkonkoma, NY) and/or an operating microscope (model MDM; Carl Zeiss, Inc., Oberkochen, Germany); 11) micro- scopic evaluation and acquisition of measurements perti- nent to the introduced catheter sites; and 12) further micro- scopic evaluation after removal of the catheters and acquisition of measurements relative to the neural and sul- cal structures of interest for our study. For didactic purposes, the first part of this study concerns the surface anatomy of the brain, whereas the second part deals with the relationship of the ASyP for cranial land- marks. Because some of the hemispheres were damaged by the catheter that was required for the second part of this study, the first part is based on fewer specimens than the second part. The measurements were recorded in millime- ters and were completed with the aid of compasses and/or flexible millimetric tapes by the first author, at least twice. Statistical Analysis All continuous variables were summarized by the mean and standard deviation. For the evaluation of the cranial– cerebral relationships, the 90th percentiles were also calcu- lated. RESULTS: PART I Surface Anatomy of the ASyP and the Suprasylvian Operculum Fig. 3. A: Photograph of a cadaveric suprasylvian operculum Morphology and Location of the ASyP. The ASyP was specimen. B: Sketch of the neural and sulcal morphology (modi- located inferior to the triangular part and anterior/inferior to fied from Ono, et al.).
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