Microsurgical anatomy and insular connectivity of the cerebral opercula

Oğuz Kağan DemirtaşDepartment of Neurosurgery, Gazi University Hospital, Ankara;
Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul;
Department of Neurosurgery, Sincan Nafiz Körfez State Hospital, Ankara;

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Abuzer GüngörDepartment of Neurosurgery, Yeditepe University School of Medicine, Istanbul;
Department of Neurosurgery, Bakirköy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul;

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Pınar ÇeltikçiDepartment of Radiology, Ankara Bilkent City Hospital, Ankara, Turkey; and

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Emrah ÇeltikçiDepartment of Neurosurgery, Gazi University Hospital, Ankara;

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Alberth Patricio Munoz-GualanDepartment of Neurosurgery, Yeditepe University School of Medicine, Istanbul;
Department of Nervous Disease and Neurosurgery, Peoples’ Friendship University of Russia, Moscow, Russia

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Fikret Hüseyin DoğuluDepartment of Neurosurgery, Gazi University Hospital, Ankara;

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Uğur TüreDepartment of Neurosurgery, Yeditepe University School of Medicine, Istanbul;

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OBJECTIVE

Radiological, anatomical, and electrophysiological studies have shown the insula and cerebral opercula to have extremely high functionality. Because of this complexity, interventions in this region cause higher morbidity compared to those in other areas of the brain. In most early studies of the insula and white matter pathways, insular dissection was begun after the opercula were removed. In this study, the authors examined the insula and deep white matter pathways to evaluate the insula as a whole with the surrounding opercula.

METHODS

Twenty formalin-fixed adult cerebral hemispheres were studied using fiber microdissection techniques and examination of sectional anatomy. Dissections were performed from lateral to medial, medial to lateral, inferior to superior, and superior to inferior. A silicone brain model was used to show the normal gyral anatomy. Sections and fibers found at every stage of dissection were photographed with a professional camera. MRI tractography studies were used to aid understanding of the dissections.

RESULTS

The relationships between the insula and cerebral opercula were investigated in detail through multiple dissections and sections. The relationship of the extreme and external capsules with the surrounding opercula and the fronto-occipital fasciculus with the fronto-orbital operculum was demonstrated. These findings were correlated with the tractography studies. Fibers of the extreme capsule connect the medial aspect of the opercula with the insula through the peri-insular sulcus. Medial to lateral dissections were followed with the removal of the central core structures, and in the last step, the medial surface of the cerebral opercula was evaluated in detail.

CONCLUSIONS

This anatomical study clarifies our understanding of the insula and cerebral opercula, which have complex anatomical and functional networks. This study also brings a new perspective to the connection of the insula and cerebral opercula via the extreme and external capsules.

ABBREVIATIONS

DTI = diffusion tensor imaging; fof = fronto-occipital fasciculus; uf = uncinate fasciculus.
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Illustration from Xu et al. (pp 1418–1430). With permission from Juan Carlos Fernandez-Miranda and The Neurosurgical Atlas by Aaron Cohen-Gadol.

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