Topographic anatomy of the insular region

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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.

Article Information

Address reprint requests to: Uğur Türe, M.D., Department of Neurosurgery, Marmara University Institute of Neurological Sciences, P.K. 53 Başĭbüyük, 81532 Maltepe, Istanbul, Turkey.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Photographs of brain specimens. Upper: The sylvian fissure is located in the lateral aspect of the left cerebral hemisphere. The frontoorbital, frontoparietal, and temporal opercula cover the insula. Lower: The insula is exposed, following excision of the opercula, to the level of the periinsular sulci. Abbreviations with white letters denote sulci and fissures. alg = anterior long insular gyrus; aps = anterior periinsular sulcus; ar = ascending ramus of sylvian fissure; ascs = anterior subcentral sulcus; asg = anterior short insular gyrus; cis = central insular sulcus; cs = central sulcus of Rolando; F2 = middle frontal gyrus; f2 = inferior frontal sulcus; hr = horizontal ramus of sylvian fissure; ia = insular apex; ips = inferior periinsular sulcus; li = limen insula; log = lateral orbital gyrus; mog = medial orbital gyrus; msg = middle short insular gyrus; op = pars opercularis of F3; or = pars orbitalis of F3; pcg = precentral gyrus; pcis = precentral insular sulcus; pcs = precentral sulcus; pg = postcentral gyrus; pis = postcentral insular sulcus; plg = posterior long insular gyrus; pog = posterior orbital gyrus; ps = postcentral sulcus; pscs = posterior subcentral sulcus; psg = posterior short insular gyrus; sis = short insular sulcus; smg = supramarginal gyrus; sps = superior periinsular sulcus; tg = transverse insular gyrus; tr = pars triangularis of F3; T1 = superior temporal gyrus; T2 = middle temporal gyrus; T3 = inferior temporal gyrus; t1 = superior temporal sulcus.

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    Artistic rendering of the left insular region (artificial retraction of opercula) with detailed nomenclature. Abbreviations with white letters denote sulci and fissures. ag = accessory insular gyrus; ahg = anterior Heschl's gyrus; aip = anterior insular point; alg = anterior long insular gyrus; aog = anterior orbital gyrus; aps = anterior periinsular sulcus; ar = ascending ramus of sylvian fissure; as = acoustic sulcus; ascs = anterior subcentral sulcus; asg = anterior short insular gyrus; atpg = anterior transverse parietal gyrus; atps = anterior transverse parietal sulcus; cis = central insular sulcus; cs = central sulcus of Rolando; ds = diagonal sulcus; fol = frontoorbital limb; fos = frontoorbital sulcus; gr = gyrus rectus; gs = gyri of Schwalbe; hr = horizontal ramus of sylvian fissure; ia = insular apex; ips = inferior periinsular sulcus; li = limen insula; log = lateral orbital gyrus; los = lateral orbital sulcus; mog = medial orbital gyrus; mos = medial orbital sulcus; msg = middle short insular gyrus; mtpg = middle transverse parietal gyrus; op = pars opercularis of F3; or = pars orbitalis of F3; os = olfactory sulcus; pcg = precentral gyrus; pcis = precentral insular sulcus; pcs = precentral sulcus; pg = postcentral gyrus; phg = posterior Heschl's gyrus; pip = posterior insular point; pis = postcentral insular sulcus; plg = posterior long insular gyrus; plol = posterolateral orbital lobule; pmol = posteromedial orbital lobule; pog = posterior orbital gyrus; pos = postinsular sulcus; ps = postcentral sulcus; pscs = posterior subcentral sulcus; psg = posterior short insular gyrus; ptpg = posterior transverse parietal gyrus; ptps = posterior transverse parietal sulcus; scg = subcentral gyrus; sis = short insular sulcus; smg = supramarginal gyrus; sopg = subopercular gyrus; sorg = suborbital gyrus; spcg = subprecentral gyrus; sps = superior periinsular sulcus; ss = sulci of Schwalbe in polar planum; stg = subtriangular gyrus; tal = terminal ascending limb of sylvian fissure; tdl = terminal descending limb of sylvian fissure; tg = transverse insular gyrus; ti = temporal incisura; tos = transverse orbital sulcus; tp = temporal pole; tpl = temporal planum; tr = pars triangularis of F3; tts = transverse temporal sulcus; T1 = superior temporal gyrus; T2 = middle temporal gyrus; t1 = superior temporal sulcus.

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    Photographs of brain specimens. Upper: Inferolateral view of the left cerebral hemisphere following removal of the temporal operculum through the inferior periinsular sulcus. The insula and its relationships to the frontoorbital and frontoparietal opercula are shown. Lower: Superolateral view of the left cerebral hemisphere following removal of the frontoorbital and frontoparietal operculum through the anterior and superior periinsular sulci, respectively. The insula and its relationship to the temporal operculum are shown. Abbreviations with white letters denote sulci and fissures. a = amygdala; ag = accessory insular gyrus; ahg = anterior Heschl's gyrus; aip = anterior insular point; alg = anterior long insular gyrus; aog = anterior orbital gyrus; ar = ascending ramus of sylvian fissure; as = acoustic sulcus; ascs = anterior subcentral sulcus; asg = anterior short insular gyrus; atpg = anterior transverse parietal gyrus; cis = central insular sulcus; cs = central sulcus of Rolando; F2 = middle frontal gyrus; gr = gyrus rectus; h = hippocampus; hr = horizontal ramus of sylvian fissure; ia = insular apex; li = limen insula; log = lateral orbital gyrus; los = lateral orbital sulcus; mog = medial orbital gyrus; mos = medial orbital sulcus; msg = middle short insular gyrus; mtpg = middle transverse parietal gyrus; op = pars opercularis of F3; or = pars orbitalis of F3; os = olfactory sulcus; pcg = precentral gyrus; pcs = precentral sulcus; pg = postcentral gyrus; phg = posterior Heschl's gyrus; pip = posterior insular point; pis = postcentral insular sulcus; plg = posterior long insular gyrus; plol = posterolateral orbital lobule; pmol = posteromedial orbital lobule; pog = posterior orbital gyrus; pos = postinsular sulcus; ps = postcentral sulcus; pscs = posterior subcentral sulcus; psg = posterior short insular gyrus; ptpg = posterior transverse parietal gyrus; scg = subcentral gyrus; sis = short insular sulcus; smg = supramarginal gyrus; spcg = subprecentral gyrus; tg = transverse insular gyrus; tos = transverse orbital sulcus; tp = temporal pole; tpl = temporal planum; tr = pars triangularis of F3; ts = temporal stem; tts = transverse temporal sulcus; T1 = superior temporal gyrus; T2 = middle temporal gyrus; t1 = superior temporal sulcus.

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    Schematic drawing showing the distances that were measured relating to the sylvian fissure and the insula. Letter coding is defined in Table 1.

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    Photograph showing a sagittal section of the left cerebral hemisphere through the insula. Abbreviations with white letters denote sulci and fissures. ahg = anterior Heschl's gyrus; alg = anterior long insular gyrus; aps = anterior periinsular sulcus; asg = anterior short insular gyrus; atpg = anterior transverse parietal gyrus; cis = central insular sulcus; cs = central sulcus of Rolando; F2 = middle frontal gyrus; f2 = inferior frontal sulcus; ips = inferior periinsular sulcus; li = limen insula; msg = middle short insular gyrus; pcg = precentral gyrus; pcs = precentral sulcus; pg = postcentral gyrus; ps = postcentral sulcus; psg = posterior short insular gyrus; sps = superior periinsular sulcus; tg = transverse insular gyrus.

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    Photograph showing an axial section of the right cerebral hemisphere through the insula, superior view. Abbreviations with white letters denote sulci and fissures. ahg = anterior Heschl's gyrus; alg = anterior long insular gyrus; aps = anterior periinsular sulcus; asg = anterior short insular gyrus; atpg = anterior transverse parietal gyrus; bf = body of fornix; c = claustrum; cg = cingulate gyrus; cis = central insular sulcus; cn = caudate nucleus; crf = crus of fornix; ec = external capsule; exc = extreme capsule; gcc = genu of corpus callosum; gp = globus pallidus; ic = internal capsule; ips = inferior periinsular sulcus; msg = middle short insular gyrus; p = putamen; pcis = precentral insular sulcus; pis = postcentral insular sulcus; plg = posterior long insular gyrus; psg = posterior short insular gyrus; scc = splenium of corpus callosum; sf = sylvian fissure; sis = short insular sulcus; t = thalamus.

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    Photograph showing a coronal section of the brain through the foramen of Monro and the amygdala, anterior view. a = amygdala; ac = anterior commissure; ahg = anterior Heschl's gyrus; alg = anterior long insular gyrus; bcc = body of corpus callosum; bf = body of fornix; c = claustrum; cg = cingulate gyrus; cis = central insular sulcus; cn = caudate nucleus; cs = central sulcus of Rolando; ec = external capsule; exc = extreme capsule; fg = fusiform gyrus; gp = globus pallidus; ic = internal capsule; ot = optic tract; p = putamen; ph = pes hippocampi; phg = posterior Heschl's gyrus; phig = parahippocampal gyrus; psg = posterior short insular gyrus; scg = subcentral gyrus; T1 = superior temporal gyrus; T2 = middle temporal gyrus; T3 = inferior temporal gyrus; t1 = superior temporal sulcus; t2 = inferior temporal sulcus.

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    Schematic drawings. Upper: Distances measured relating to the insula and the lateral ventricle. Letter coding is defined in Table 2. Lower: Distances measured relating to the insula and various landmarks on the cerebral surface. Letter coding is defined in Table 3.

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    Photographs of brain specimens. Upper Left: Lateral surface of the left cerebral hemisphere. Following application of the fiber dissection technique, the superior longitudinal fasciculus (slf) is revealed and the frontoorbital, frontoparietal, and temporal opercula, which cover the insula, are preserved. Upper Right: The sylvian fissure has been opened completely and retraction of the opercula demonstrates the insula. Center Left: Removal of the opercula demonstrates the relationship between the insula and the slf. Center Right: Removal of the insular cortex demonstrates the extreme capsule (exc), which is connected to the white matter of the opercula (arrows). Lower: Demonstration of the uncinate fasciculus (uf), occipitofrontal fasciculus (of), external capsule (ec), putamen (p), and slf. ahg = anterior Heschl's gyrus; aip = anterior insular point; alg = anterior long insular gyrus; aps = anterior periinsular sulcus; ar = ascending ramus of sylvian fissure; as = acoustic sulcus; ascs = anterior subcentral sulcus; asg = anterior short insular gyrus; atpg = anterior transverse parietal gyrus; c = claustrum; cis = central insular sulcus; cs = central sulcus of Rolando; F1 = superior frontal gyrus; f1 = superior frontal sulcus; hr = horizontal ramus of sylvian fissure; ia = insular apex; ic = internal capsule; ips = inferior periinsular sulcus; li = limen insula; log = lateral orbital gyrus; mog = medial orbital gyrus; msg = middle short insular gyrus; mtpg = middle transverse parietal gyrus; op = pars opercularis of F3; or = pars orbitalis of F3; p = putamen; pcg = precentral gyrus; pcis = precentral insular sulcus; pcs = precentral sulcus; pg = postcentral gyrus; phg = posterior Heschl's gyrus; pip = posterior insular point; pis = postcentral insular sulcus; plg = posterior long insular gyrus; plol = posterolateral orbital lobule; pog = posterior orbital gyrus; pscs = posterior subcentral sulcus; psg = posterior short insular gyrus; ptpg = posterior transverse parietal gyrus; scg = subcentral gyrus; sis = short insular sulcus; sog = suborbital gyrus; sopg = subopercular gyrus; spcg = subprecentral gyrus; sps = superior periinsular sulcus; tal = terminal ascending limb of sylvian fissure; tdl = terminal descending limb of sylvian fissure; tg = transverse insular gyrus; tr = pars triangularis of F3; tts = transverse temporal sulcus; T1 = superior temporal gyrus; T3 = inferior temporal gyrus.

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    Photograph showing the medial surface of the left hemisphere after midsagittal section. Following partial removal of the thalamus, hypothalamus, internal capsule, globus pallidus, putamen, external capsule, claustrum, and extreme capsule, the medial surface of the insular cortex is demonstrated. The central insular sulcus (cis) appears to be a gyrus and the anterior long insular gyrus (alg) appears to be a sulcus. ac = anterior commissure; acs = anterior calcarine sulcus; apes = anterior perforated substance; bcc = body of corpus callosum; bf = body of fornix; cf = column of fornix; cg = cingulate gyrus; cis = central insular sulcus; crf = crus of fornix; cs = callosal sulcus; fi = fimbria; gcc = genu of corpus callosum; istc = isthmus cinguli; oln = olfactory nerve; phig = parahippocampal gyrus; psg = posterior short insular gyrus; rcc = rostrum of corpus callosum; scc = splenium of corpus callosum; sic = sublentiform portion of internal capsule; u = uncus; us = uncal sulcus.

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    Upper: Drawing of the coronal section through the third ventricle and insula showing the relationships between the insula and the putamen. Lower: Drawing of the lateral view of the insula showing the relationship between the insula and the putamen (dark area). Letter coding is defined in Table 4.

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