Topographic anatomy of the insular region

OBJECT: The insula is one of the paralimbic structures and constitutes the invaginated portion of the cerebral cortex, forming the base of the sylvian fissure. The authors provide a detailed anatomical study of the insular region to assist in the process of conceptualizing a reliable surgical approach to allow for a successful course of surgery. METHODS: The topographic anatomy of the insular region was studied in 25 formalin-fixed brain specimens (50 hemispheres). The periinsular sulci (anterior, superior, and inferior) define the limits of the frontoorbital, frontoparietal, and temporal opercula, respectively. The opercula cover and enclose the insula. The limen insula is located in the depths of the sylvian fissure and constitutes the anterobasal portion of the insula. A central insular sulcus divides the insula into two portions, the anterior insula (larger) and the posterior insula (smaller). The anterior insula is composed of three principal short insular gyri (anterior, middle, and posterior) as well as the accessory and transverse insular gyri. All five gyri converge at the insular apex, which represents the most superficial aspect of the insula. The posterior insula is composed of the anterior and posterior long insular gyri and the postcentral insular sulcus, which separates them. The anterior insula was found to be connected exclusively to the frontal lobe, whereas the posterior insula was connected to both the parietal and temporal lobes. Opercular gyri and sulci were observed to interdigitate within the opercula and to interdigitate the gyri and sulci of the insula. Using the fiber dissection technique, various unique anatomical features and relationships of the insula were determined. CONCLUSIONS: The topographic anatomy of the insular region is described in this article, and a practical terminology for gyral and sulcal patterns of surgical significance is presented. This study clarifies and supplements the information presently available to help develop a more coherent surgical concept.     

Arteries of the insula

OBJECT: The insula is located at the base of the sylvian fissure and is a potential site for pathological processes such as tumors and vascular malformations. Knowledge of insular anatomy and vascularization is essential to perform accurate microsurgical procedures in this region. METHODS: Arterial vascularization of the insula was studied in 20 human cadaver brains (40 hemispheres). The cerebral arteries were perfused with red latex to enhance their visibility, and they were dissected with the aid of an operating microscope. Arteries supplying the insula numbered an average of 96 (range 77-112). Their mean diameter measured 0.23 mm (range 0.1-0.8 mm), and the origin of each artery could be traced to the middle cerebral artery (MCA), predominantly the M2 segment. In 22 hemispheres (55%), one to six insular arteries arose from the M1 segment of the MCA and supplied the region of the limen insulae. In an additional 10 hemispheres (25%), one or two insular arteries arose from the M3 segment of the MCA and supplied the region of either the superior or inferior periinsular sulcus. The insular arteries primarily supply the insular cortex, extreme capsule, and, occasionally, the claustrum and external capsule, but not the putamen, globus pallidus, or internal capsule, which are vascularized by the lateral lenticulostriate arteries (LLAs). However, an average of 9.9 (range four-14) insular arteries in each hemisphere, mostly in the posterior insular region, were similar to perforating arteries and some of these supplied the corona radiata. Larger, more prominent insular arteries (insuloopercular arteries) were also observed (an average of 3.5 per hemisphere, range one-seven). These coursed across the surface of the insula and then looped laterally, extending branches to the medial surfaces of the opercula. CONCLUSIONS: Complete comprehension of the intricate vascularization patterns associated with the insula, as well as proficiency in insular anatomy, are prerequisites to accomplishing appropriate surgical planning and, ultimately, to completing successful exploration and removal of pathological lesions in this region.     

Diffusion tensor tractography of the temporal stem on the inferior limiting sulcus

OBJECT: The aim of this study was to use diffusion tensor tractography (DTT) to define the 3D relationships of the uncinate fasciculus, anterior commissure, inferior occipitofrontal fasciculus, inferior thalamic peduncle, and optic radiation and to determine the positioning landmarks of these white matter tracts. METHODS: The anatomy was studied in 10 adult human brain specimens. Brain DTT was performed in 10 healthy volunteers. Diffusion tensor tractography images of the white matter tracts in the temporal stem were obtained using the simple single region of interest (ROI) and multi-ROIs based on the anatomical knowledge. RESULTS: The posteroinferior insular point is the anterior extremity of intersection of the Heschl gyrus and the inferior limiting sulcus. On the inferior limiting sulcus, this point is the posterior limit of the optic radiation, and the temporal stem begins at the limen insulae and ends at the posteroinferior insular point. The distance from the limen insulae to the tip of the temporal horn is just one third the length of the temporal stem. The uncinate fasciculus comprises the core of the anterior temporal stem, behind which the anterior commissure and the inferior thalamic peduncle are located, and they occupy the anterior third of the temporal stem. The inferior occipitofrontal fasciculus passes through the entire temporal stem. The most anterior extent of the Meyer loop is located between the anterior tip of the temporal horn and the limen insulae. Most of the optic radiation crosses the postmedian two thirds of the temporal stem. CONCLUSIONS: On the inferior limiting sulcus, the posteroinferior insular point is a reliable landmark of the posterior limit of the optic radiations. The limen insulae, anterior tip of the temporal horn, and posteroinferior insular point may be used to localize the white matter fibers of the temporal stem in analyzing magnetic resonance imaging or during surgery.     

Epilepsy and insula

The insula is the only cortical part of the brain that is not visible on the surface of the hemisphere, because it is totally covered by the frontoparietal and temporal opercula. The insula is triangular in shape and is separated from the opercula by the anterior, superior, and inferior peri-insular sulci. It is morphologically divided into two parts by the central insular sulcus. The anterior part of the insula bears three short gyri, and its posterior part contains two long gyri. The vascular supply of the insula is mainly provided by the M2 segment of the middle cerebral artery, a substantial obstacle to any open or stereotactic procedure aiming at the insular region. The insula is functionally involved in cardiac rhythm and arterial blood pressure control, as well as in visceromotor control and in viscerosensitive functions. There is substantial evidence that the insula is involved as a somesthetic area, including a major role in the processing of nociceptive input. The role of the insula in some epilepsies was recently investigated by means of depth electrode recordings made following Talairach's stereoelectroencephalography (SEEG) methodology. It appears that ictal signs associated with an insular discharge are very similar to those usually attributed to mesial temporal lobe seizures. Ictal symptoms associated with insular discharges are mainly made up of respiratory, viscerosensitive (chest or abdominal constriction), or oroalimentary (chewing or swallowing) manifestations. Unpleasant somatosensory manifestations, always opposite the discharging side, are also frequent. Ictal signs arising from the insula occur in full consciousness; these are always simple partial seizures. Seizures arising from the temporal lobe always invade the insular region, but in approximately 10% of cases, the seizures originate in the insular cortex itself. These data explain that there has been a rebirth of interest in the insula from a surgical perspective over the past few years. The literature contains no reports of cases of resection of insular cortex alone; most insular resections are performed in the context of temporal resection, when there is some evidence of seizures originating in the insula itself. Such procedures are risky and their efficacy, in terms of postoperative surgical outcome, has not yet been clearly assessed. In this context, less invasive procedures, such as SEEG-guided radiofrequency thermolesions of the insular cortex, are under investigation.     

Vascularization of the anal canal]

The arterial blood supply of the anal canal derives from the superior, middle and inferior rectal arteries, whose branches reach the anal submucosa. Three main arterial trunks in the right anterior, right posterior and left lateral positions can be isolated below the pectinate line. They come, for the most important part, from the superior rectal artery. On the course of the anal submucosal venous plexus are fusiform, saccular or serpiginous dilatations confined to the lower half of the anal canal. This plexus is mainly tributary of the superior rectal vein to the portal system and secondly, of the middle and inferior rectal veins and the lateral sacral veins to the inferior vena cava. Arterio-venous direct communications have been demonstrated by serial section and by radiography of cadaveric specimens and by selective inferior mesenteric arteriography in patients. The erectile property of the anal submucosa as suggested by large vascular spaces, arterio-venous shunts and glomic systems may function in the erectile mechanism.     

Microanatomical study of the insular perforating arteries

Background

The insular perforating arteries originate from the middle cerebral artery. They have only been very partially described up to now. In the literature, they come from the M2 segment and three types are listed: the short, medium and long perforators. The first two types supply the claustrum as well as the external and extreme capsules.

Objective

We describe the anatomy of long perforating insular arteries and their arterial contribution to the main white matter bundles of the oval center of Vieussens.

Materials and method

Twenty adult cadaveric hemispheres were studied after perfusion of the arteries and veins with colored latex. The arteries were dissected and photographed under an operating microscope.

Results

The long insular perforating arteries come from the M2 segment or from the junction of the M2 and M3 segments and sometimes from the M3 segment. They often perforate the insular cortex on the top of the posterior short insular gyrus and the insular long gyri, or in the superior peri-insular sulcus, before coming together in the oval center. At this level, they give arterial contribution to the main white matter bundles such as corticospinal and corticonuclear tracts for motricity, and the arcuate fasciculus and the occipitofrontal tract for language in the dominant hemisphere.

Conclusion

These perforating arteries have to be carefully respected during insular surgery to avoid neurologic weakness.     

Distribution of cortical activation during visuospatial n-back tasks as revealed by functional magnetic resonance imaging

Human neuroimaging studies conducted during visuospatial working memory tasks have inconsistently detected activation in the prefrontal cortical areas depending presumably on the type of memory and control tasks employed. We used functional magnetic resonance imaging to study brain activation related to the performance of a visuospatial n-back task with different memory loads (0-back, 1-back and 2-back tasks). Comparison of the 2-back versus 0-back tasks revealed consistent, bilateral activation in the medial frontal gyrus (MFG), superior frontal sulcus and adjacent cortical tissue (SFS/SFG) in all subjects and in six out of seven subjects in the intraparietal sulcus (IPS). Activation was also detected in the inferior frontal gyrus, medially in the superior frontal gyrus, precentral gyrus, superior and inferior parietal lobuli, occipital visual association areas, anterior and posterior cingulate areas and in the insula. Comparison between the 1- back versus 0-back tasks revealed activation only in a few brain areas. Activation in the MFG, SFS/SFG and IPS appeared dependent on memory load. The results suggest that the performance of a visuospatial working memory task engages a network of distributed brain areas and that areas in the dorsal visual pathway are engaged in mnemonic processing of visuospatial information.      

Microanatomy and surgical relevance of the olfactory cistern

All surgical approaches to the anterior skull base involve the olfactory cistern and have the risk of damaging the olfactory nerve. The purpose of this study was to describe the microanatomical features of the olfactory cistern and discuss its surgical relevance. In this study, the olfactory cisterns of 15 formalin-fixed adult cadaveric heads were dissected using a surgical microscope. The results showed that the olfactory cistern was situated in the superficial part of the olfactory sulcus, which separated the gyrus retus from the orbital gyrus. In coronal section, the cistern was triangular in shape; its anterior part enveloped the olfactory bulbs and was high and broad; its posterior part was medial-superior to internal carotid artery and was also much broader. There were one or several openings in the inferior wall of the posterior part in 53.4% of the cisterns. The olfactory cistern communicated with the surrounding subarachnoind cisterns through these openings. The middle part of the olfactory cistern gradually narrowed down posteriorly. Most cisterns were spacious with a few fibrous trabeculas and bands between the olfactory nerves and cistern walls. However 23% of the cisterns were narrow with the cistern walls tightly encasing the olfactory nerve. There were two or three of arterial loops in each olfactory sulcus, from which long, fine olfactory arteries originated. The olfactory arteries coursed along the olfactory nerve and gave off many terminal branches to provide the main blood supply to the olfactory nerve in most cisterns, but the blood supply was in segmental style in a few cisterns. Moreover, the veins of the cistern appeared to be more segmental than the olfactory arteries in most cisterns. These results suggested that most olfactory cisterns are spacious with relatively independent blood supply, and it is reasonable to separate the olfactory tract with its independent blood supply from the frontal lobe by 1-2 cm in the subfrontal approach, the pterional approach, or anterior interhemispheric approach. However, in the minority of cases, separation of the olfactory tract is not safe because of the anterior origin of the olfactory arteries or segmental blood supply. It is difficult to separate the olfactory nerve without any damage to the olfactory nerve, even with very skilled hands.     

Anatomical relationship between the renal venous arrangement and the kidney collecting system

The anatomical relationships between the renal venous arrangement and the pelviocaliceal system were studied in 52, 3-dimensional polyester resin corrosion endocasts. In 53.8% of the cases, there were 3 large venous trunks and in 28.8% there were 2 venous trunks joining to form the main renal vein. Intrarenal veins demonstrated free anastomoses that were disposed in 3 systems of longitudinal arcades (stellate, arcuate and interlobar veins). There were large venous collars around caliceal necks and also horizontal arches crossing over calices to link anterior and posterior veins. In 84.6% of the cases the upper caliceal group was encircled anteriorly and posteriorly by venous plexuses, which coursed parallel to the infundibulum. In 50.0% of the cases the lower caliceal group also was enriched by 2 venous plexuses. A close relationship existed between a large inferior tributary of the renal vein and the anterior aspect of the ureteropelvic junction in 40.4% of the cases. In 69.2% of the cases there was a posterior (retropelvic) vein: in 48.1% this vein had a close relationship to the junction of the pelvis with the upper calix and in 21.1% it crossed the middle posterior surface of the renal pelvis.     

Variability of the territories of the major cerebral arteries.

Recent morphological and functional studies on the circle of Willis suggest that the areas of supply of the six major cerebral arteries show a considerable variation in distribution, in contrast to the relatively consistent pattern generally accepted; therefore, the cortical and intracerebral distribution of the territories of these arteries was investigated in 25 unfixed human brains obtained at routine autopsy. The six major cerebral arteries were simultaneously injected under the same pressure with different-colored Araldite F mixtures under standardized conditions to obtain the most realistic territorial distribution. The cortical boundaries were examined and recorded in relation to the cerebral gyri and sulci, and the territories of the anterior, middle, and posterior cerebral arteries were analyzed and compared. The intracerebral distribution of these territories was investigated after the injected brains were cut in parallel slices. The variability of the territories of these arteries was much larger than generally described in the literature. Twenty-six variations in the territory of the anterior cerebral artery, 17 variations in the area of the middle cerebral artery, and 22 variations in the area of the posterior cerebral artery were found in the cortex of 50 hemispheres. Intracerebrally, the anterior, middle, and posterior cerebral arteries contributed in varying degrees to the blood supply of the lobar white matter, the internal capsule, the caudate nucleus, and the lentiform nucleus. The large variation in the area in which the cortical and intracerebral boundaries between these territories was located was demonstrated by illustrating the minimum and maximum extent of each. The results are compared with prior findings, and their implications for both experimental model studies and clinical practice are discussed.     

The transsylvian trans-limen insular approach to the crural,ambient and interpeduncular cisterns

Summary Background. The authors introduce the transsylvian trans-limen insular approach to the crural, ambient and interpeduncular cisterns.Method. The transsylvian trans-limen insular approach was performed in 7 patients; 3 for aneurysm, 2 for isolated temporal horn hydrocephalus, one for tumour and one for an arteriovenous malformation. This approach is summarized in 4 procedures; the exposure of the inferior limiting sulcus of the insular cortex, the exposure of the inferior horn of the lateral ventricle, the dissection of the inferior part of the choroidal fissure and the splitting of the inferior border of the limen insula.Findings. Four among 7 patients underwent surgery for the lesions in the crural or ambient cistern. The other 3 patients underwent surgery for the lesion in the interpeduncular cistern. Two patients of the latter group postoperatively had temporal lobe infarction.Conclusions. The transsylvian trans-limen insular approach may be indicated for lesions in the crural and the anterior ambient cisterns, and the lesions which need wider exposure of the interpeduncular cistern. For the former lesions, this approach can afford good results. For the latter lesions, careful brain retraction and some other techniques to avoid temporal lobe infarction are necessary. Further neuropsychological assessment should be also necessary to prove the validity of this approach.     

Microvascular anatomy of the hippocampal formation.

The hippocampal vessels were examined in 25 forebrain hemispheres injected with india ink or methylmethacrylate. There were two to seven hippocampal arteries, which measured 200-800 microns in diameter. The anterior hippocampal artery (AHA), which was present in 88.2% of the hemispheres, most often originated from the posterior cerebral and the anterior temporal arteries, that is, within the rostral hippocampo-parahippocampal arterial complex. It arose from the anterior choroidal artery in 29.4% of the hemispheres. The AHA extended between the uncus and the parahippocampal gyrus, and it supplied the head of the hippocampus. The middle hippocampal artery was constant. It most often arose from the posterior cerebral and the common temporal arteries. The middle hippocampal artery coursed just caudal to the uncus, in close relationship with the lateral posterior choroidal artery, and it usually supplied the middle part of the hippocampal formation. The posterior hippocampal artery, which existed in 94.1% of the hemispheres, most often arose from the posterior cerebral and the splenial arteries. It irrigated the caudal part of the hippocampal formation. The anastomoses connecting the posterior, middle, and the anterior hippocampal arteries were present in 29.4% of the hemispheres. The hippocampal arteries gave rise to the straight vessels, which divided into the large and the small intrahippocampal arteries. The highest density of the capillary network was noted in the pyramidal and molecular layers of the hippocampal formation. The clinical significance of the obtained microanatomical findings is discussed.     

Brain activity during stimulation of the trigeminal nerve with noxious heat.

OBJECTIVE: The aim of this study was to observe areas of brain activation with painful hot stimulation to the trigeminal nerve. STUDY DESIGN: Nine healthy pain-free women (mean age 26.2 +/- 6.9 yrs) with a natural, regular menstrual cycle participated in the study. Whole-brain functional magnetic resonance imaging (fMRI) data were acquired for each participant on day 2 or 3 after the onset of menses using echo-planar imaging at 1.5T with near-isotropic spatial resolution and a temporal resolution of 4 s. RESULTS: Whole-brain fMRI with a Peltier thermode inside the head coil yielded a feasible imaging protocol with little disturbance from the thermode. Painful thermal stimulation of the left trigeminal system activated discrete brain regions within the insula, cingulate gyrus, thalamus, inferior parietal lobe/postcentral gyrus, right middle and inferior frontal gyri, cuneus, precuneus, and precentral gyrus. CONCLUSION: Painful stimulation of the trigeminal nerve resulted in activation of similar brain areas generally known for pain processing of painful peripheral stimulation.     

Dominance for vestibular cortical function in the non-dominant hemisphere

The aim of this (15)O-labelled H(2)O bolus positron emission tomography (PET) study was to analyse the hemispheric dominance of the vestibular cortical system. Therefore, the differential effects of caloric vestibular stimulation (right or left ear irrigation with warm water at 44 degrees C) on cortical and subcortical activation were studied in 12 right-handed and 12 left-handed healthy volunteers. Caloric irrigation induces a direction-specific sensation of rotation and nystagmus. Significant regional cerebral blood flow increases were found in a network within both hemispheres, including the superior frontal gyrus/sulcus, the precentral gyrus and the inferior parietal lobule with the supramarginal gyrus. These areas correspond best to the cortical ocular motor centres, namely the prefrontal cortex, the frontal eye field and the parietal eye field, known to be involved in the processing of caloric nystagmus. Furthermore, distinct temporo-parietal activations could be separated in the posterior part of the insula with the adjacent superior temporal gyrus, the inferior parietal lobule and precuneus. These areas fit best to the human homologues of multisensory vestibular cortex areas identified in the monkey and correspond to the parieto-insular vestibular cortex (PIVC), the visual temporal sylvian area (VTS) and areas 7 and 6. Further cortical activations were seen in the anterior insula, the inferior frontal gyrus and anterior cingulum. The subcortical activation pattern in the putamen, thalamus and midbrain is consistent with the organization of efferent ocular motor pathways. Cortical and subcortical activation of the described areas was bilateral during monaural stimulation, but predominant in the hemisphere ipsilateral to the stimulated ear and exhibited a significant right hemispheric dominance for vestibular and ocular motor structures in right-handed volunteers. Similarly, a significant left hemispheric dominance was found in the 12 left-handed volunteers. Thus, this PET study showed for the first time that cortical and subcortical activation by vestibular caloric stimulation depends (i) on the handedness of the subjects and (ii) on the side of the stimulated ear. Maximum activation was therefore found when the non-dominant hemisphere was ipsilateral to the stimulated ear, i.e. in the right hemisphere of right-handed subjects during caloric irrigation of the right ear and in the left hemisphere of left-handed subjects during caloric irrigation of the left ear. The localization of handedness and vestibular dominance in opposite hemispheres might conceivably indicate that the vestibular system and its hemispheric dominance, which matures earlier during ontogenesis, determine right- or left-handedness.     

Sylvian fissure arteriovenous malformations

We have operated on 16 cases of arteriovenous malformation (AVM) in and around the sylvian fissure. We call these lesions "sylvian fissure AVMs" and classify them into four subdivisions, namely, pure, lateral, medial, and deep AVMs. By others, they have been variously called AVMs of the basal ganglia, insula, anterior choroidal artery, frontal lobe, or temporal lobe. These sylvian fissure AVMs showed similar angiographic findings: the feeders in all cases were branches of the middle cerebral artery; in some cases, additional feeders from the anterior and posterior choroidal and posterior communicating arteries were present also. We describe the characteristic features of these AVMs from the anatomical and surgical points of view. The surgical results were satisfactory in 15 cases (no additional neurological deficits), and 1 patient died.     

Localization of hand motor activation in Broca's pli de passage moyen

OBJECT: The object of this study was to identify a reliable surface landmark for the hand motor area and to demonstrate that it corresponds to a specific structural component of the precentral gyrus. METHODS: Positron emission tomography (PET) activation studies for hand motor function were reviewed in 12 patients in whom magnetic resonance imaging results were normal. Each patient performed a hand opening and closing task. Using a computer-assisted three-dimensional reconstruction of the surface of each hemisphere studied, the relationship of the hand motor area with cortical surface landmarks was evaluated. CONCLUSIONS: The region of hand motor activation can be reliably identified on the surface of the brain by assessing anatomical relationships to nearby structures. After identification of the central sulcus, the superior and middle frontal gyrus can be seen to arise from the precentral gyrus at a perpendicular angle. A bend or genu in the precentral gyrus is constantly seen between the superior and middle frontal gyrus, which points posteriorly (posteriorly convex). The location of hand motor function, identified using PET activation studies, is within the central sulcus at the apex of this posteriorly pointing genu. The apex of the genu of the precentral gyrus leads to a deep cortical fold connecting the pre- and postcentral gyri and elevating the floor of the central sulcus. This deep fold was described by Paul Broca as the pli de passage fronto-parietal moyen, and the precentral bank of the pli de passage represents the anatomical substratum of hand motor function. Observers blinded to the results of the activation studies were able to identify the hand motor area reliably after instruction in using these surface landmarks.     

Successful treatment of huge arteriovenous malformation in the basal ganglia

This report describes successful therapeutic results of a huge and high flow arteriovenous malformation (AVM) in the left basal ganglionic region. A 39-year-old female was admitted to our hospital presenting recent progression of aphasia, hemianopsia, hemiparesis, hemisensory disturbance on the right side. Progression of disturbance in consciousness was rapid, and the patient became comatose shortly after admission. A CT scan revealed a densely enhanced lesion in the left basal ganglia which caused aqueductal obstruction and hydrocephalus. Angiography demonstrated a huge and high flow AVM that was supplied by the anterior and posterior choroidal arteries, the lateral striate arteries and the insular branches of the middle cerebral arteries. This AVM drained into the vein of Galen via the inferior ventricular and basal vein. The draining vein was markedly dilated at the level of midbrain by a prominent stenosis of the junction between the vein of Galen and straight sinus, and it severely compressed the midbrain. Superselective embolization of the feeding arteries was done in two sessions. This was followed by surgical intervention for the embolized AVM one month after the second session. Embolization and surgery were carried out under barbiturate protection to reduce the risk of normal perfusion pressure break-through. The patient recovered well from these interventions without any hemodynamic changes and showed dramatic improvement of all focal neurological abnormalities. Postoperative angiography showed only a small residue of AVM.     

Surgical resection of intrinsic insular tumors: complication avoidance

OBJECT: Surgical resection of tumors located in the insular region is challenging for neurosurgeons, and few have published their surgical results. The authors report their experience with intrinsic tumors of the insula, with an emphasis on an objective determination of the extent of resection and neurological complications and on an analysis of the anatomical characteristics that can lead to suboptimal outcomes. METHODS: Twenty-two patients who underwent surgical resection of intrinsic insular tumors were retrospectively identified. Eight tumors (36%) were purely insular, eight (36%) extended into the temporal pole, and six (27%) extended into the frontal operculum. A transsylvian surgical approach, combined with a frontal opercular resection or temporal lobectomy when necessary, was used in all cases. Five of 13 patients with tumors located in the dominant hemisphere underwent craniotomies while awake. The extent of tumor resection was determined using volumetric analyses. In 10 patients, more than 90% of the tumor was resected; in six patients, 75 to 90% was resected; and in six patients, less than 75% was resected. No patient died within 30 days after surgery. During the immediate postoperative period, the neurological conditions of 14 patients (64%) either improved or were unchanged, and in eight patients (36%) they worsened. Deficits included either motor or speech dysfunction. At the 3-month follow-up examination, only two patients (9%) displayed permanent deficits. Speech and motor dysfunction appeared to result most often from excessive opercular retraction and manipulation of the middle cerebral artery (MCA), interruption of the lateral lenticulostriate arteries (LLAs), interruption of the long perforating vessels of the second segment of the MCA (M2), or violation of the corona radiata at the superior aspect of the tumor. Specific methods used to avoid complications included widely splitting the sylvian fissure and identifying the bases of the periinsular sulci to define the superior and inferior resection planes, identifying early the most lateral LLA to define the medial resection plane, dissecting the MCA before tumor resection, removing the tumor subpially with preservation of all large perforating arteries arising from posterior M2 branches, and performing craniotomy with brain stimulation while the patient was awake. CONCLUSIONS: A good understanding of the surgical anatomy and an awareness of potential pitfalls can help reduce neurological complications and maximize surgical resection of insular tumors.     

Three systems of insular functional connectivity identified with cluster analysis

Despite much research on the function of the insular cortex, few studies have investigated functional subdivisions of the insula in humans. The present study used resting-state functional connectivity magnetic resonance imaging (MRI) to parcellate the human insular lobe based on clustering of functional connectivity patterns. Connectivity maps were computed for each voxel in the insula based on resting-state functional MRI (fMRI) data and segregated using cluster analysis. We identified 3 insular subregions with distinct patterns of connectivity: a posterior region, functionally connected with primary and secondary somatomotor cortices; a dorsal anterior to middle region, connected with dorsal anterior cingulate cortex, along with other regions of a previously described control network; and a ventral anterior region, primarily connected with pregenual anterior cingulate cortex. Applying these regions to a separate task data set, we found that dorsal and ventral anterior insula responded selectively to disgusting images, while posterior insula did not. These results demonstrate that clustering of connectivity patterns can be used to subdivide cerebral cortex into anatomically and functionally meaningful subregions; the insular regions identified here should be useful in future investigations on the function of the insula.     

The arterial system of the greater omentum

The aim of our study is to establish a pattern of distribution of the arteries of greater omentum. Right omental arteries supply the anterior lamina and the left ones the posterior lamina (in 82% there is an initial independent left-right distribution). In 18% it is mixed, the two territories being supplied by both anterior and posterior omental arteries. The classic pattern with three main arterial arches (one infra-gastric and two inferior marginal) was identified in 24% cases. More frequent (45%) is the pattern with two transverse main arteries, one superior and the other inferior (with a variable number of intermediate arteries). In 51% cases the infra-colic arch is dominant; in 14% cases it is thinner. The absence of arterial arches may be partly substituted by a dense capillary network. The laminar arterial distribution of greater omentum was expressed into more patterns.