Anatomical analysis of different hemispherotomy procedures based on dissection of cadaveric brains

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Object. Functional hemispherectomy, itself a modification of anatomical hemispherectomy, has been further modified to a less invasive method (hemispherotomy), in which cortical resection is minimized and the rest of the affected hemisphere is functionally isolated by transecting its projection and commissural fibers. Although descriptions of three different types of hemispherotomy procedures have been published, the authors believe that it is important to develop a common and universally acceptable method based on a systematic analysis of topographic anatomy and neuronal connections. To this end, they have analyzed the three aforementioned procedures on the basis of meticulous fiber dissections in previously frozen formalin-fixed human brains.

Methods. The brain anatomy pertinent to surgical hemispherotomy is described in conjunction with dissection studies in 14 previously frozen, formalin-fixed human brains. The anatomical landmarks necessary for performing particular neuronal fiber resections are identified, and their relationships with operative methods are discussed, with an emphasis on commonalities among the three hemispherotomy procedures.

Conclusions. In this analysis the authors confirmed that hemispherotomy typically consists of four common procedures: 1) interruption of the internal capsule and corona radiata; 2) resection of the medial temporal structures; 3) transventricular corpus callosotomy; and 4) disruption of the frontal horizontal fibers. After meticulous dissection of cadavers, the authors have designated a reliable method for performing these four operations that may be applicable as a commonly used procedure.

Article Information

Address reprint requests to: Michiharu Morino, M.D., Department of Neurosurgery, Graduate School of Medicine, Osaka City University, 1–4–3 Asahi-machi, Abeno-ku, Osaka 545–8585, Japan. email: mitchy@med.osaka-cu.ac.jp.

© AANS, except where prohibited by US copyright law.

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Figures

  • View in gallery

    Photographs of cadaveric brain specimens. A: Lateral surface of the left cerebral hemisphere. Following application of the fiber dissection method, the frontoparietal operculum covering the insula (ins) is resected and the superior longitudinal fasciculus (slf) is revealed. B: Magnified view (× 4) of A. C: Removal of the insular cortex reveals the extreme capsule (exc). Following removal of the superior longitudinal fasciculus, the internal capsule (ic) appears. D: Magnified view (× 4) of C. E: The lateral ventricle (lv) appears after interruption of the internal capsule. F: Magnified view (× 4) of E. Fl = frontal lobe; tl = temporal lobe.

  • View in gallery

    Photographs of cadaveric brain specimens. Upper: After the interruption of the internal capsule, the inferior horn (ih) is revealed by disruption of the fibers emerging from the insula and the temporal stem (ts). Lower: The amygdala (amy) and the hippocampus (hp) appear at the anterior tip of the inferior horn. Ce = collateral eminence; cp = choroid plexus; pca = pericallosal artery.

  • View in gallery

    Photographs of cadaveric brain specimens. Upper Left: Entering into the lateral ventricle after interruption of the internal capsule, the septum pellucidum (sp) and the ventral surface of the corpus callosum (vscc) can be recognized. Upper Right: Callosotomy is performed along the course of the pericallosal artery (pca). Lower Left: Following the pericallosal artery to the base of the frontal lobe, the interruption of the genu of corpus callosum (gcc) is achieved. Lower Right: Following the pericallosal artery posteriorly, the splenium of the corpus callosum (scc) is cut at the transitional point between the hippocampus and fornix. After the splenium is amputated, the vein of Galen (vg) can be recognized at the medial side of the splenium. Fx = falx; hpt = hippocampal tail; tr = trigonum.

  • View in gallery

    Photographs of cadaveric brain specimens. Upper: The horizontal frontal fibers (hff) are sectioned subcortically from the lateral ventricle up to the level of the sphenoid ridge. Lower: After application of the fiber dissection procedure, the horizontal frontal fibers include the occipitofrontal fasciculus (off) and uncinate fasciculus (uf). Ac = anterior commissure; cr = corona radiata; gp = globus pallidus; p = putamen; sw = sphenoid wing.

  • View in gallery

    Photographs of cadaveric brain specimens. Left: Lateral view of hemispherotomy, in which the yellow arrow indicates the resection of temporal structures; the blue arrow indicates the transventricular corpus callosotomy; and the red arrow indicates the disruption of horizontal frontal fibers. Right: Coronal view of hemispherotomy, in which the white arrow indicates the interruption of the internal capsule from the opercular cavity; the black arrow indicates the transventricular corpus callosotomy; the red line indicates the disruption of the emerging fibers from the insula; and the blue arrow indicates the disruption of the temporal stem and resection of the medial temporal structures. C = claustrum; cc = corpus callosum; cg = cingulate gyrus; cn = caudate nucleus; ec = external capsule; fg = fusiform gyrus; phg = parahippocampal gyrus; T1 = superior temporal gyrus; T2 = middle temporal gyrus; T3 = inferior temporal gyrus.

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