Arteries of the insula

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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.

Article Information

Address reprint requests to: Uğur Türe, M.D., Marmara University Institute of Neurological Sciences, P.K. 53 Basibüyük, 81532 Maltepe - Istanbul, Turkey. email: ugurture@turk.net.

© AANS, except where prohibited by US copyright law.

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Figures

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    Photographs of brain specimens. Upper Left: The lateral surface of the left hemisphere is supplied by the M4 and M5 segments of the MCA. Upper Right: The same specimen is shown following removal of the entire opercula with preservation of all segments of the MCA. Lower: The same specimen. The M3, M4, and M5 segments of the MCA have been removed, and the M2 segment, which supplies the insula, has been preserved over the insular cortex. White letters denote sulci and fissures. 1 = lateral orbitofrontal artery; 2 = prefrontal artery; 3 = precentral artery; 4 = central artery; 5 = anterior parietal artery; 6 = posterior parietal artery; 7 = angular artery; 8 = temporooccipital artery; 9 = posterior temporal artery; 10 = middle temporal artery; 11 = anterior temporal artery; 12 = temporal polar artery; ang = angular gyrus; ar = ascending ramus of sylvian fissure; cs = central sulcus of Rolando; F1 = superior frontal gyrus; F2 = middle frontal gyrus; F3 = inferior frontal gyrus; f1 = superior frontal sulcus; f2 = inferior frontal sulcus; hr = horizontal ramus of sylvian fissure; it = inferior trunk of M2 segment; op = pars opercularis of F3; or = pars orbitalis of F3; pcg = precentral gyrus; pcs = precentral sulcus; pg = postcentral gyrus; ps = postcentral sulcus; smg = supramarginal gyrus; st = superior trunk of M2 segment; T1 = superior temporal gyrus; T2 = middle temporal gyrus; T3 = inferior temporal gyrus; t1 = superior temporal sulcus; t2 = inferior temporal sulcus; tal = terminal ascending limb of sylvian fissure; tb = temporal branch of the MCA; tdl = terminal descendinglimb of sylvian fissure; tr = pars triangularis of F3; tts = transverse temporal sulcus.

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    Photographs of brain specimens. Upper: Inferior view is shown of left MCA in the region of the anterior perforated substance following removal of the temporal lobe. The M1 segment is retracted with forceps to expose the LLAs (lla). Lower: The temporal branch of the M1 (tb) is raised to rotate the M1 segment and expose the frontal branch of the MCA (fb). The arrow indicates an LLA arising from the frontal branch (lateral orbitofrontal artery). The asterisk indicates the main bifurcation of the MCA. I = olfactory nerve; III = oculomotor nerve; A1 = precommunicating segment of ACA; ach = anterior choroidal artery; li = limen insulae; M1 = sphenoidal segment of the MCA; on = optic nerve; ot = optic tract; P2 = ambient segment of posterior cerebral artery; pco = posterior communicating artery. See previous figure legend for additional abbreviations.

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    Drawings showing anatomical variations in the cortical branches of M1. A: The M1 segment gave rise to a temporal branch in 57.5% of the hemispheres. B: The M1 segment gave rise to temporal and frontal branch arteries in 35% of the hemispheres. C: The M1 segment gave rise to a frontal branch in 2.5% of the hemispheres. D: The M1 segment gave rise to no major cortical branches (only LLAs and uncal arteries) in 5% of the hemispheres. The LLAs are denoted by dotted lines. A1 = precommunicating segment of the ACA.

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    Photographs of brain specimens. Upper: The insula is shown following removal of the frontal, parietal, occipital, and temporal lobes from the periinsular sulci. The arteries of the insula originate from the M2 segment. The insuloopercular arteries (arrows) supply the insula and operculum. Lower: Fiber dissection of this area reveals vascularization of the lentiform nuclei (which have been removed) and vascularization of the internal capsule by the LLAs (arrow), which arise from M1 segment. ac = anterior commissure; alg = anterior long insular gyrus; asg = anterior short insular gyrus; cis = central insular sulcus; ia = insular apex; ic = internal capsule; it = inferior trunk of M2; msg = middle short insular gyrus; P2 = ambient segment of the posterior cerebral artery; plg = posterior long insular gyrus; psg = posterior short insular gyrus. See previous figure legends for additional abbreviations.

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    Anterior view of the left cerebral hemisphere following removal of the frontoorbital and frontoparietal opercula. The M3 segment of the superior trunk of the MCA located in the anterior and superior periinsular sulci has been severed. The inferior trunk, which supplies the temporal lobe, is preserved. See previous figure legends for abbreviations.

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    Photographs of brain specimens. Upper: Arteries of the left insula. Frontal and temporal branches contribute to the vascularization of the insula in the region of the anterior and inferior periinsular sulci, respectively. Lower: The central artery is shown providing branches to the central insular sulcus. aps = anterior periinsular sulcus; ips = inferior periinsular sulcus; pcis = precentral insular sulcus; pis = postcentral insular sulcus; sis = short insular sulcus. See previous figure legends for additional abbreviations.

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    Photographs of brain specimens. Upper: The perforator-like insular artery (arrow) supplies the insular apex (ia). Lower: Coronal section is shown of the left cerebral hemisphere through the sylvian vallecula. The perforator-like insular artery (arrow) originates from the M2 segment and supplies the insular cortex, extreme capsule (exc), claustrum (c), and external capsule (ec). cc = corpus callosum; cg = cingulate gyrus; cn = caudate nucleus; p = putamen. See previous figure legends for additional abbreviations.

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    Drawings showing that approximately 85 to 90% of insular arteries were short and supplied the insular cortex (i) and extreme capsule; 10% were medium sized and supplied, in addition, the claustrum and external capsule; and the remainder 3 to 5% were long and extended as far as the corona radiata (cr). a = amygdala; gp = globus pallidus; p = putamen. See previous figure legends for additional abbreviations.

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    Left: Coronal T1-weighted MR image revealing a heterogeneous lesion (AVM) in the striate region. Right: Anteroposterior projection of a right ICA angiogram demonstrating a striate AVM. Note the feeding vessels of the AVM originating from the insular arteries, which arise from the M2 segment and the LLAs.

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