Brain Anatomy and Neurosurgical Approaches: A Practical, Illustrated, Easy-to-Use Guide

Foreword
Preface
Acknowledgments
Contents
About the Editors
Basic Concepts in Microsurgery
1 Introduction
2 Become an Expert Cost Time
3 Watching and Learning
4 Decision-Making Process
5 Why to Training?
6 Materials and Tools
7 Simulation
8 Cadaveric Animal Tissues
8.1 Cadaveric Human Tissues
8.2 Live Animal Models
9 Technology Simulating Neurosurgery
10 Global Rating Scales
11 Conclusion
References
Part I: The Surface
Surgical Anatomy of the Scalp
1 Introduction
2 Historical Aspects
3 Scalp Layers
4 Sensitive Innervation of the Scalp
5 Motor Innervation of the Scalp
6 Vascular Supply
6.1 Superficial Temporal Artery (STA)
6.2 Occipital Artery
6.3 Posterior Auricular Artery
7 Venous Drainage
8 Healing Process
9 Conclusions
References
Surgical Anatomy of the Skull
1 Ethmoid Bone
2 Sphenoid Bone
3 Osseous Relationships
4 Vascular Relationships
5 Neural Relationships
6 Sphenoidal Sinus
7 Temporal Bone
8 Lateral Surface
9 The Tympanic Part
10 The Mastoid Part
11 The Squamous Part
12 The Petrous Part
13 The Styloid Part
14 Frontal, Parietal, and Occipital Bone
15 Frontal Bone
16 Parietal Bone
17 Occipital Bone
18 Conclusion
References
Surgical Anatomy of the Temporal Bone and Transtemporal Approaches
1 Introduction
2 Temporal Bone Anatomy
2.1 Squamous Portion
2.2 Mastoid Portion
2.3 Petrous Bone
2.4 Tympanic Bone
2.5 Styloid Process
2.6 Eustachian Tube
3 Inner Ear
3.1 Membranous Labyrinth
3.2 Utricle
3.3 Sacule
3.4 Vestibular Aqueduct, Endolymphatic Sac and Duct
3.5 Cochlear Aqueduct
3.6 Semicircular Canals
3.7 Cochlea
4 Petroclival Region
5 Infratemporal Fossa
5.1 Muscular Relationships
6 Pterygopalatine Fossa
6.1 Vascular Relationships
7 Surgical Approaches
7.1 Middle Fossa Approach
7.2 Anterior Petrosectomy
7.3 Translabyrinthine Approach
7.4 Combined Supra/Infratentorial Presigmoid Approach (“Petrosal Approach”)
7.5 Retrosigmoid Approach
7.6 Subtemporal Preauricular Infratemporal Fossa Approach
7.7 Postauricular Transtemporal Approach
8 Discussion
9 Conclusion
References
Surgical Anatomy of the Sulci and Gyrus of the Brain
1 Introduction
2 Brain Subdivision into Lobes
3 Cerebral Surfaces, Sulci and Gyri
4 Sulcal Key Points
4.1 Frontotemporal Keypoints (Fig. 4)
4.1.1 Anterior Sylvian Point (ASyP) × Anterior Squamous Point (ASqP)
4.1.2 Inferior Rolandic Point (IRP) × Superior Squamous Point (SSqP)
4.1.3 Inferior Frontal Sulcus/Precentral Sulcus Meeting Point (IFS/PreCS) × Stephanion (St)
4.1.4 Posterior Extremity of the Superior Temporal Sulcus (postSTS) × Temporoparietal Point (TPP)
4.2 Posterior Frontal Keypoints (Fig. 5)
4.2.1 Superior Frontal Sulcus/Precentral Sulcus Meeting Point (SFS/PreCS) × Posterior Coronal Point (PCoP)
4.2.2 Superior Rolandic Point (SRP) × Superior Sagittal Point (SSP)
4.3 Parietal Keypoints (Fig. 6)
4.3.1 The Intraparietal Sulcus/Postcentral Sulcus Meeting Point (IPS/PostCS) × Intraparietal Point (IPP)
4.3.2 Supramarginal Gyrus (SMG) × Euryon (Eu)
4.4 Occipital Keypoints (Fig. 7)
4.4.1 External Occipital Fissure Depth of the Parieto-Occipital Sulcus (EOF/POS) × Lambdoid/Sagittal Point (La/Sa)
4.4.2 Distal End of the Calcarine Fissure (dCaF) × Opisthocranion (OpCr)
4.5 Temporo-Occipital Base Keypoints (Fig. 8)
4.5.1 Preauricular Depression (PreAuDepr) and Parietomastoid Suture/Squamous Suture Meeting Point (PaMaSut/SqSut Meet Pt)
4.6 Suboccipital Base Keypoints (Fig. 9)
4.6.1 Asterion (Ast) and OccipitoMastoid Suture/Mastoid Notch Point (OccMaSut/MaNaPt)
References
Surgical Anatomy of the Temporal Lobe
1 Introduction
2 Surgical Anatomy
2.1 Temporal Lobe Limits
2.2 Temporal Lobe Sulci
2.3 Temporal Gyri
2.4 Considerations on Temporal Gyri and Sulci
2.5 Hippocampus
2.6 Hippocampal Head
2.7 Hippocampal Body
2.8 Hippocampal Tail
2.9 Hippocampal Vascularization and Vascular Relationships
2.9.1 Anterior Choroidal Artery
2.9.2 Posterior Cerebral Artery
2.9.3 HA and Its Parent Vessels
2.9.4 Vascular Arcades and Anastomoses
2.10 Amygdala
2.11 Choroidal Fissure
2.12 Vascular Relationships
2.13 Optic Radiation
2.14 Inferior Fronto-Occipital Fasciculus
2.15 Uncinate Fasciculus
2.16 Temporal Stem
2.17 Language in the Temporal Lobe
2.17.1 Language Input
2.17.2 Semantic Versus Phonological Pathways
2.17.3 Ventral Semantic Stream
2.17.4 Dorsal Phonological Stream
2.18 Brain Hodotopy
2.19 Sylvian Cistern
2.20 Superficial Sylvian Veins
2.21 Middle Cerebral Artery
3 Temporal Surgery for Epilepsy
3.1 Neurological Deficits Following Temporal Epilepsy Surgery
3.2 Standard Temporal Lobectomy
3.3 The Selective Amygdalohippocampectomy
3.3.1 Transsylvian Approach
3.3.2 Transtemporal (Niemeyer’s Technique)
3.3.3 Subtemporal Technique
3.4 Anterior Temporal Lobectomy (ATL) Versus Selective Amygdalohippocampectomy (SAH)
4 Illustrative Cases
5 Conclusion
References
Surgical Anatomy of the Insula
1 Historic
1.1 Sylvian Fissure
1.2 The Insula
1.3 Associated White Matter Tracts
1.4 Insular Cortex and Associated Lesions
2 Clinical Condition: Cerebral Cavernous Malformation
3 Physical Examination
4 Anatomy Characteristics
5 Anatomy Approach: Transsylvian
6 Clinical Condition: Glioma
7 Physical Examination
8 Anatomy Characteristics
9 Anatomy Approach: Transcortical
10 Conclusion
References
Surgical Anatomy of the Cerebellum
1 Introduction
2 Anatomical Divisions
3 Cerebellar Surfaces
3.1 Tentorial Surface
3.2 Suboccipital Surface
3.3 Petrosal Surface
4 Cerebellar Nuclei and Fiber
5 Surgical Corridors
5.1 Telovelar Approach
5.2 Retrosigmoid Approach
5.3 Supracerebelar Infratentorial Approach
5.4 Transcortical Approach
6 Conclusion
References
Surgical Anatomy of the Brainstem
1 History of Brainstem Anatomy and Surgery
2 The Midbrain
2.1 Anatomy & Neurophysiology
2.2 Safe Zones/Approaches
2.2.1 Posterolateral Midbrain Approach: Lateral Mesencephalic Sulcus (LMS)
2.2.2 Anterolateral Midbrain Approaches: Anterior Mesencephalic Zone (AMZ)/Perioculomotor Zone
2.2.3 Dorsal Midbrain Approaches: Intercollicular Region
3 The Pons
3.1 Anatomy & Neurophysiology
3.2 Safe Zones/Approaches
3.2.1 Ventrolateral Pontine Approaches: Lateral Pontine Zone/Peritrigeminal Zone/Supratrigeminal Zone
3.2.2 Dorsal Pontine Approaches: Supracollicular & Infracollicular Zones/Median Sulcus of the Fourth Ventricle (Interfacial)
4 The Medulla
4.1 Anatomy & Neurophysiology
4.2 Safe Zone/Approaches
4.2.1 Anterior Medullary Approaches: Anterolateral Sulcus (ALS)/Olivary Zone/Lateral Medullary Zone
4.2.2 Posterior Medullary Approaches: Posterior Median Sulcus and Posterior Intermediate Sulcus
5 Conclusion
References
Part II: The Cisterns
Surgical Anatomy of the Sylvian Fissure
1 Introduction
2 History
3 Anatomy of the Sylvian Corridor
4 Indications
5 Surgical Technique
6 Conclusion
References
Sylvian Fissure: Anatomical and a Clinical Correlations
1 Sylvian Fissure and Cistern
2 Fronto-Orbital Operculum
3 Frontoparietal Operculum
4 Temporal Operculum
5 Insula
6 Arteries of the Sylvian Cistern
7 Arteries: Angiographic View
8 Veins of the Sylvian Cistern
References
Surgical Anatomy of Interhemispheric Fissure
1 Introduction
2 Surgical Anatomy of IF
2.1 Step 1: Non-invasive Step
2.2 Step 2: Invasive Step
2.3 Step 3: Resection Surgery
2.3.1 Anterior Interhemispheric (AIH) Approach for the Tumors in and around the Third Ventricle
Illustrative Case
2.3.2 AIH Approach with Anterior Callosal (AC) Section
Illustrative Case
2.3.3 Anterior Interhemispheric Transcallosal Transventricular Approach
Illustrative Cases
Large Neurocytoma (Fig. 6)
Large Ventricular Meningioma (Fig. 7)
2.3.4 Interhemispheric Transcallosal Trans-hippocampal Commissure Trans-internal Cerebral Vein Approach
Midbrain Cavernous Malformation (CM) (Fig. 8)
Occipital Transtentorial (OTT) Approach for Midbrain CM
3 Discussion
3.1 SMA Lesion
3.2 Various IF Approaches to Remove Deep-Seated Lesions
4 Conclusion
References
Surgical Anatomy of the Quadrigeminal Cistern and Pineal Gland
1 Introduction
2 Anatomy
3 Surgical Indications
4 Hydrocephalus Management
5 Patient Positioning
5.1 Sitting (or Semi-sitting) Position
5.2 Lateral and Park Bench Position (¾ Prone)
5.3 Prone Position
6 Surgical Approaches
6.1 Median and Paramedian Infratentorial Supracerebellar
6.2 Transcallosal Interhemispheric
6.3 Occipital Transtentorial
6.4 Transcortical Transventricular
6.5 Endoscopic Approaches
7 Postoperative Care and Complications
8 Conclusions
References
Surgical Anatomy of Cerebellopontine Cistern
1 Introduction
2 History
3 Surgical Anatomy
4 Pathologies and Clinical Symptoms
5 Radiological Diagnosis
6 Surgical Approaches
7 Case Studies
7.1 Case 1: Small Vestibular Schwannoma
7.2 Case 2: Large Vestibular Schwannoma
7.3 Case 3: Cerebellopontine Angle Meningioma
7.4 Case 4: Petroclival Meningioma
7.5 Case 5: Epidermoid Cyst
7.6 Case 6: Trigeminal Neuralgia
8 Complications and How to Avoid
9 Pearls and Tips
References
Surgical Anatomy for Auditory Brainstem Implantation
1 Introduction
2 The Cochlear Nerve
3 Cochlear Nuclei
3.1 Histological Anatomy
3.2 Surgical Anatomy
4 The Cochlear Nucleus as an Anatomic Interface for Auditory Brainstem Implants
References
Part III: The Central Core
Surgical Anatomy of the White Fiber Tracts
1 General Considerations
2 White Substance in the Cerebral Hemispheres
3 White Matter Sublevels
3.1 Association Fibers
3.1.1 In the Superolateral Surface of the Brain
Superior Longitudinal Fasciculus
Uncinate Fasciculus
Fronto-Occipital Fasciculus
Inferior Longitudinal Fasciculus
Subcallosal Fasciculus
3.1.2 In the Middle Surface of the Brain
Cingulum (Rodete Fasciculus)
3.2 Commissural Fibers
3.2.1 The Corpus Callosum
3.2.2 The Anterior Commissure
3.2.3 Fornix (Hippocampal Commissure)
3.2.4 Posterior Commissure
3.2.5 Commissure Habenular
3.2.6 Septum Pellucidum
3.3 Projection Fibers
3.3.1 Internal Capsule
References
Surgical Anatomy of the Basal Ganglia and Thalamus
1 Introduction
2 Microsurgical Anatomy
3 Discussion
References
Part IV: The Ventricles
Surgical Anatomy of the Lateral Ventricles
1 Introduction
2 Lateral Ventricle
2.1 Front Horn
2.2 Body
2.3 Atrium and Occipital Horn
2.4 Temporal Horn
3 Discussion
4 Surgical Applications
4.1 Approaches to the Temporal Horn and Mesial Structures
4.2 Approaches to the Ventricular Atrium
5 Conclusion
References
Surgical Anatomy of the Third Ventricle
1 Introduction
2 Anterior Approaches
2.1 Interhemispheric Anterior Trans-callosal Approach (IATcA)
2.1.1 Transforaminal Approach
2.1.2 Inter-forniceal Approach
2.1.3 Trans-choroidal Approach
2.1.4 Sub-choroidal Approach
2.2 Sub-frontal Approach
2.2.1 Trans-lamina Terminalis
2.2.2 Opticocarotid Approach
2.2.3 Subchiasmatic Approach
3 Lateral Approaches
3.1 Sub-temporal Approach
3.2 Trans-sylvian Approach
4 Posterior Approaches
4.1 Supra-cerebellar Infra-tentorial (ScItA)
4.2 Interhemispheric Posterior Trans-callosal Approach
4.3 Occipital Trans-tentorial Approach
5 Conclusions
References
Surgical Anatomy of the Fourth Ventricle
1 Introduction
2 Anatomy
3 Fourth Ventricle Roof
3.1 Upper Ventricular Roof
3.2 Inferior Ventricular Roof
4 Fourth Ventricle Floor
5 Cerebellar–Brainstem Fissures
6 Lateral Recesses
7 Choroidal Plexus
8 Vascular Relationships
9 Approaches to the Fourth Ventricle
10 Case Examples
10.1 Case 1 Subependymoma
10.2 Case 2 Hemangioblastoma
11 Conclusions
References
Part V: The Skull Base
Surgical Anatomy of the Anterior Fossa
1 Anterior Cranial Fossa Anatomy
2 Surgical Approaches and Techniques
2.1 Bifrontal Craniotomy
2.2 Frontolateral Craniotomy
2.3 Supraorbital Craniotomy
2.4 Endoscopic Endonasal Approaches
3 Pearls and Tips (Pathology Specific)
3.1 Olfactory Groove (OG) Meningiomas
3.2 Planum Sphenoidale and Tuberculum Sellae Meningiomas
3.3 Ethmoidal Dural Arteriovenous Fistula
3.4 Anterior Cranial Fossa Meningocele
3.5 Sinonasal Malignancies with Intracranial Extension
4 Conclusions
References
Surgical Anatomy of the Orbit
1 Overview
2 Pertinent Anatomical Considerations
3 Epidemiology of Orbital Lesions
4 Preoperative Evaluation
4.1 Radiological Evaluation
4.2 Surgery Purpose and Possibilities
5 Transorbital Approaches
5.1 Superior Orbitotomy
5.1.1 Upper Eyelid Crease
Surgical Technique [11, 12]
5.2 Medial Orbitotomy
5.2.1 Transcaruncular Approach
Surgical Technique [11–13]
5.3 Inferior Orbitotomy
5.3.1 Transconjunctival Approach [11, 12, 14]
Surgical Technique
5.4 Lateral Orbitotomy
5.4.1 Surgical Technique [11, 12, 15]
6 Endonasal Endoscopic Medial Approach
6.1 Surgical Technique
6.1.1 Step 1: Removal of the Anterior Wall of the Sphenoid Sinus
6.1.2 Step 2: Removal of the Lamina Papyracea
6.1.3 Step 3: Opening of the Periorbita
6.1.4 Step 4: Intraconal Dissection
7 Transcranial Approaches
7.1 Focus Fronto-Orbito-Zygomatic Approach (FOCA)
7.1.1 Concept and Rationale
7.1.2 Surgical Technique
Step 1: Patient Position and Skin Incision
Step 2: Soft Tissue Dissection and Muscle Mobilization
Step 3: Bone Dissection
Step 4: Epidural Dissection
Step 5: Removal of the Orbital Roof, the Roof of the Optical Canal, and Anterior Clinoid Process
Step 6: Dural Opening
Step 7: Dural, Bone, and Soft Tissue Reconstruction
7.2 Clinical Cases
7.2.1 Case # 1
7.2.2 Case # 2
7.2.3 Case # 3
8 Conclusions
References
Surgical Anatomy of the Middle Fossa
1 Introduction
2 Osseous Anatomy of the Middle Fossa
3 Sphenoid Bone
4 Sphenoid Sinus
5 The Temporal Bone
6 Dural Folds and Ligaments
7 Sellar and Parasellar Regions
8 Cavernous Sinus
9 Oculomotor Nerve (III CN)
10 Trochlear Nerve (IV CN)
11 Trigeminal Nerve (V CN)
12 Abducens Nerve (VI CN)
13 Internal Carotid Artery
14 Cavernous Sinus Triangles
15 Anteromedial Triangle
16 Paramedial Triangle
17 Oculomotor Triangle
18 Parkinson’s Triangle
19 Anterolateral Triangle
20 Lateral Triangle
21 Posterolateral Triangle (Glasscock)
22 Posteromedial Triangle (Kawase)
23 Inferomedial Paraclival Triangle
24 Inferolateral Paraclival Triangle (Trigeminal Triangle)
25 Middle Cranial Fossa as a Surgical Region
26 Neural Margins
27 Arterial Margins
28 Venous Margins
29 Cisternal Margins
30 Approaches to the Middle Fossa
References
Surgical Anatomy of the ParaSellar Region
1 Sellar Region
2 Parasellar Region
3 Anatomy of Cavernous Sinus
3.1 Walls of the Cavernous Sinus
3.2 The Course of Cranial Nerves
3.3 Cavernous Carotid Artery
3.4 Venous Connections
4 Parasellar Triangles
5 Cavernous Sinus Triangles
5.1 Clinoidal Triangle
5.2 Oculomotor Triangle
5.3 Supratrochlear Triangle
5.4 Infratrochlear Triangle
6 Middle Fossa Triangles
6.1 Anteromedial Triangle
6.2 Anterolateral Triangle
6.3 Posterolateral Triangle (Glasscock’s Triangle)
6.4 Posteromedial Triangle (Kawase’s Triangle)
7 Paraclival Triangles
7.1 Inferolateral Triangle
7.2 Inferomedial Triangle
8 Endoscopic Anatomy of Cavernous Sinus
9 Parasellar Pathologies
References
Surgical Anatomy of the Anterior Incisural Space
1 Anatomy
2 Cisternal Relations
3 Ventricular Relations
4 Cranial Nerve Relationships
5 Arterial Relations
6 Venous Relations
7 Aneurysms in the Anterior Incisural Space
8 Arteriovenous Malformations in the Anterior Incisural Space
9 Tumors in the Anterior Incisural Space
10 Anterior Incisural Width as a Preoperative Indicator for Intradural Space Assessment
11 A Possible New Approach to Treating Posterior Circulation Brain Aneurysms
12 Conclusions
References
Surgical Anatomy of the Cavernous Sinus
1 Introduction
2 Histo-Embryological Background
3 Surgical Anatomy of the Cavernous Sinus
3.1 The Parasellar Lodge
3.2 The Venous Plexuses of the Parasellar Lodge
3.3 The Motor Ocular Nerves
3.3.1 The Oculomotor Nerve
3.3.2 The Trochlear Nerve
3.3.3 The Abducens Nerve
3.4 The Trigeminal Cave and the Trigeminal Nerve
3.5 The Internal Carotid Artery and Its Intracavernous Segments
3.6 The ICA Proximal Control
3.7 The ICA Distal Control
4 Surgical Anatomy of the Cavernous Sinus Approaches
4.1 Endocranial Microsurgical Approaches
4.2 Expanded Endonasal Transsphenoidal Approach
4.3 Percutaneous Access to the Cavernous Sinus
5 Anatomical Imaging of the Cavernous Sinus
5.1 Magnetic Resonance Imaging (MRI)
5.2 Computed Tomography (CT)
5.3 Digital Subtraction Angiography (DSA)
6 Conclusion
References
Surgical Anatomy of the Petroclival Region
1 Surgical Considerations
2 Surgical Approaches to the Petroclival Region
References
Surgical Anatomy of the Far Lateral Approach and Jugular Foramen
1 Introduction
2 Osseous Anatomy
2.1 Occipital Bone
2.1.1 Squamous Part of the Occipital Bone
2.1.2 Condylar Part of the Occipital Bone
2.2 Atlas
3 Sequential Steps of the Far Lateral Approach
3.1 Positioning
3.2 Skin Incision
3.3 Muscular Dissection
3.4 Craniotomy
3.4.1 Transcondylar Extension
3.4.2 Supracondylar Extension
3.4.3 Paracondylar Extension
3.5 Dural Opening
3.6 Intradural Exposure
4 Case Illustration
References
Surgical Anatomy of the Foramen Magnum
1 Bone Anatomy
2 Suboccipital Muscles
3 Surgical Considerations
4 Far Lateral Approach
5 Midline Suboccipital Approach
References
Surgical Anatomy of the Approaches to the Brainstem
1 Introduction
2 Surgical Technique and Approaches
2.1 Orbitozygomatic
2.2 Subtemporal/Transtentorial
2.3 Anterior Petrosectomy
2.4 Retrosigmoid
2.5 Far Lateral
2.6 Transpetrosal Retrolabyrinthine Presigmoid
2.7 Suboccipital Telovelar
2.8 Median Supracerebellar Infratentorial
2.9 Endoscopic/Endoscopic-Assisted Approaches
3 Safe Entry Zones to the Brainstem
3.1 Midbrain
3.1.1 Anterior Mesencephalic Zone (AMZ)
3.1.2 Lateral Mesencephalic Sulcus (LMS)
3.1.3 Intercollicular Region
3.2 Pons
3.2.1 Peritrigeminal Zone
3.2.2 Supratrigeminal Zone
3.2.3 Lateral Pontine Zone
3.2.4 Rhomboid Fossa
3.3 Medulla
3.3.1 Anterolateral Sulcus of the Medulla
3.3.2 Posterior Median Sulci of the Medulla
3.3.3 Olivary Zone
3.3.4 Lateral Medullary Zone/Inferior Cerebellar Peduncle
4 Clinical Presentation
5 Neuroradiology
6 Differential Diagnosis
6.1 Diffuse tumors (Type I)—Diffuse Intrinsic Pontine Glioma (DIPG)
6.2 Focal Brainstem Tumors (Type II)
6.3 Dorsally Exophytic Brainstem Tumors (Exophytic tumors) – (Type III)
6.4 Cervicomedullary Tumors (Type IV)
7 Surgical Indications and Treatment
7.1 Diffuse Intrinsic Pontine Glioma (DIPG)
7.2 Focal Brainstem Tumors
8 Conclusions
References
Index