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Central core of the cerebrum

Laboratory investigation

Chan-Young Choi, Seong-Rok Han, Gi-Taek Yee and Chae-Heuck Lee

Object

The purpose of this study was to understand 3D relationships of white matter fibers and subcortical areas of gray matter in the central core.

Methods

The lateral and medial aspects of 4 cerebral hemispheres were dissected, applying the fiber dissection technique under the microscope.

Results

The central core between the insula and midline includes the extreme, external, and internal capsules; claustrum; putamen; globus pallidus; caudate nucleus; amygdala; diencephalon; substantia innominata; fornix; anterior commissure; mammillothalamic tract; fasciculus retroflexus; thalamic peduncles, including optic and auditory radiations; ansa peduncularis; thalamic fasciculus; and lenticular fasciculus. It is attached to the remainder of the cerebral hemisphere by the cerebral isthmus, which is composed of white matter fibers located between the dorsolateral margin of the caudate nucleus and the full circumference of the circular sulcus of insula. The rostral fibers of the corpus callosum are included in the frontal portion of the cerebral isthmus.

Conclusions

It is very useful for neurosurgeons to facilitate the understanding of spatial relationships and pertinent surgical approaches in and around the central core with a highly complex anatomy by using fiber dissection.

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Chang-Hyun Lee, Hae-Won Koo, Seong Rok Han, Chan-Young Choi, Moon-Jun Sohn and Chae-Heuck Lee

OBJECTIVE

De novo seizure following craniotomy (DSC) for nontraumatic pathology may adversely affect medical and neurological outcomes in patients with no history of seizures who have undergone craniotomies. Antiepileptic drugs (AEDs) are commonly used prophylactically in patients undergoing craniotomy; however, evidence supporting this practice is limited and mixed. The authors aimed to collate the available evidence on the efficacy and tolerability of levetiracetam monotherapy and compare it with that of the classic AED, phenytoin, for DSC.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched for studies that compared levetiracetam with phenytoin for DSC prevention. Inclusion criteria were adult patients with no history of epilepsy who underwent craniotomy with prophylactic usage of phenytoin, a comparator group with levetiracetam treatment as the main treatment difference between the two groups, and availability of data on the numbers of patients and seizures for each group. Patients with brain injury and previous seizure history were excluded. DSC occurrence and adverse drug reaction (ADR) were evaluated. Seizure occurrence was calculated using the Peto odds ratio (POR), which is the relative effect estimation method of choice for binary data with rare events.

RESULTS

Data from 7 studies involving 803 patients were included. The DSC occurrence rate was 1.26% (4/318) in the levetiracetam cohort and 6.60% (32/485) in the phenytoin cohort. Meta-analysis showed that levetiracetam is significantly superior to phenytoin for DSC prevention (POR 0.233, 95% confidence interval [CI] 0.117–0.462, p < 0.001). Subgroup analysis demonstrated that levetiracetam is superior to phenytoin for DSC due to all brain diseases (POR 0.129, 95% CI 0.039–0.423, p = 0.001) and tumor (POR 0.282, 95% CI 0.117–0.678, p = 0.005). ADRs in the levetiracetam group were cognitive disturbance, thrombophlebitis, irritability, lethargy, tiredness, and asthenia, whereas rash, anaphylaxis, arrhythmia, and hyponatremia were more common in the phenytoin group. The overall occurrence of ADR in the phenytoin (34/466) and levetiracetam (26/432) groups (p = 0.44) demonstrated no statistically significant difference in ADR occurrence. However, the discontinuation rate of AEDs due to ADR was 53/297 in the phenytoin group and 6/196 in the levetiracetam group (POR 0.266, 95% CI 0.137–0.518, p < 0.001).

CONCLUSIONS

Levetiracetam is superior to phenytoin for DSC prevention for nontraumatic pathology and has fewer serious ADRs that lead to discontinuation. Further high-quality studies that compare levetiracetam with placebo are necessary to provide evidence for establishing AED guidelines.

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Myoung Soo Kim, You Sun Kim, Hye Kyung Lee, Ghi Jai Lee, Chan Young Choi and Chae Heuck Lee

The authors describe a patient with an adamantinomatous craniopharyngioma (CPG) arising in the cerebellopontine angle (CPA), who also had probable Gardner's syndrome. This 31-year-old man presented with headache and dizziness. Brain CT and MRI showed a 5 × 4–cm lesion with multiple small calcifications in the left CPA. The patient underwent suboccipital craniotomy with tumor removal. Histopathological findings indicated an adamantinomatous CPG. This patient also showed characteristics of Gardner's syndrome. Although this syndrome is associated with intracranial neoplasms, it is unclear whether patients with both Gardner's syndrome and CPG are part of the heterogeneity of Gardner's syndrome.