The Topography of the Frontal Terminations of the Uncinate Fasciculus Revisited Through Focused Fiber Dissections: Shedding Light on a Current Controversy and Introducing the Insular Apex as a Key Anatomoclinical Area

BACKGROUND

Recent studies advocate a connectivity pattern wider than previously believed of the uncinate fasciculus that extends to the ventrolateral and dorsolateral prefrontal cortices. These new percepts on the connectivity of the tract suggest a more expansive role for the uncinate fasciculus. Our aim was to shed light on this controversy through fiber dissections.

METHODS

Twenty normal adult human formalin-fixed cerebral hemispheres were used. Focused dissections on the insular, orbitofrontal, ventromedial, ventrolateral, and dorsolateral prefrontal areas were performed to record the topography of the frontal terminations of the uncinate fasciculus.

RESULTS

Three discrete fiber layers were consistently disclosed: the first layer was recorded to terminate at the posterior orbital gyrus and pars orbitalis, the second layer at the posterior two thirds of the gyrus rectus, and the last layer at the posterior one third of the paraolfactory gyrus. The insular apex was documented as a crucial landmark regarding the topographic differentiation of the uncinate and occipitofrontal fasciculi (i.e., fibers that travel ventrally belong to the uncinate fasciculus whereas those traveling dorsally are occipitofrontal fibers).

CONCLUSIONS

The frontal terminations of the uncinate fasciculus were consistently documented to project to the posterior orbitofrontal area. The area of the insular apex is introduced for the first time as a crucial surface landmark to effectively distinguish the stems of the uncinate and occipitofrontal fasciculi. This finding could refine the spatial resolution of awake subcortical mapping, especially for insular lesions, and improve the accuracy of in vivo diffusion tensor imaging protocols.

Deciphering the frontostriatal circuitry through the fiber dissection technique: direct structural evidence on the morphology and axonal connectivity of the fronto-caudate tract

OBJECTIVE

The authors sought to investigate the very existence and map the topography, morphology, and axonal connectivity of a thus far ill-defined subcortical pathway known as the fronto-caudate tract (FCT) since there is a paucity of direct structural evidence regarding this pathway in the relevant literature.

METHODS

Twenty normal adult cadaveric formalin-fixed cerebral hemispheres (10 left and 10 right) were explored through the fiber microdissection technique. Lateral to medial and medial to lateral dissections were carried out in a tandem manner in all hemispheres. Attention was focused on the prefrontal area and central core since previous diffusion tensor imaging studies have recorded the tract to reside in this territory.

RESULTS

In all cases, the authors readily identified the FCT as a fan-shaped pathway lying in the most medial layer of the corona radiata and traveling across the subependymal plane before terminating on the superolateral margin of the head and anterior part of the body of the caudate nucleus. The FCT could be adequately differentiated from adjacent fiber tracts and was consistently recorded to terminate in Brodmann areas 8, 9, 10, and 11 (anterior pre-supplementary motor area and the dorsolateral, frontopolar, and fronto-orbital prefrontal cortices). The authors were also able to divide the tract into a ventral and a dorsal segment according to the respective topography and connectivity observed. Hemispheric asymmetries were not observed, but instead the authors disclosed asymmetry within the FCT, with the ventral segment always being thicker and bulkier than the dorsal one.

CONCLUSIONS

By using the fiber microdissection technique, the authors provide sound structural evidence on the topography, morphology, and connectional anatomy of the FCT as a distinct part of a wider frontostriatal circuitry. The findings are in line with the tract's putative functional implications in high-order motor and behavioral processes and can potentially inform current surgical practice in the fields of neuro-oncology and functional neurosurgery.

Dissecting the default mode network: direct structural evidence on the morphology and axonal connectivity of the fifth component of the cingulum bundle

OBJECTIVE

Although a growing body of data support the functional connectivity between the precuneus and the medial temporal lobe during states of resting consciousness as well as during a diverse array of higher-order functions, direct structural evidence on this subcortical circuitry is scarce. Here, the authors investigate the very existence, anatomical consistency, morphology, and spatial relationships of the cingulum bundle V (CB-V), a fiber tract that has been reported to reside close to the inferior arm of the cingulum (CingI).

METHODS

Fifteen normal, formalin-fixed cerebral hemispheres from adults were treated with Klingler's method and subsequently investigated through the fiber microdissection technique in a medial to lateral direction.

RESULTS

A distinct group of fibers is invariably identified in the subcortical territory of the posteromedial cortex, connecting the precuneus and the medial temporal lobe. This tract follows the trajectory of the parietooccipital sulcus in a close spatial relationship with the CingI and the sledge runner fasciculus. It extends inferiorly to the parahippocampal place area and retrosplenial complex area, followed by a lateral curve to terminate toward the fusiform face area (Brodmann area [BA] 37) and lateral piriform area (BA35). Taking into account the aforementioned subcortical architecture, the CB-V allegedly participates as a major subcortical stream within the default mode network, possibly subserving the transfer of multimodal cues relevant to visuospatial, facial, and mnemonic information to the precuneal hub. Although robust clinical evidence on the functional role of this stream is lacking, the modern neurosurgeon should be aware of this tract when manipulating cerebral areas en route to lesions residing in or around the ventricular trigone.

CONCLUSIONS

Through the fiber microdissection technique, the authors were able to provide original, direct structural evidence on the existence, morphology, axonal connectivity, and correlative anatomy of what proved to be a discrete white matter pathway, previously described as the CB-V, connecting the precuneus and medial temporal lobe.

Dorsal component of the superior longitudinal fasciculus revisited: novel insights from a focused fiber dissection study

OBJECTIVE

The aim of this study was to investigate the anatomical consistency, morphology, axonal connectivity, and correlative topography of the dorsal component of the superior longitudinal fasciculus (SLF-I) since the current literature is limited and ambiguous.

METHODS

Fifteen normal, adult, formalin-fixed cerebral hemispheres were studied through a medial to lateral fiber microdissection technique. In 5 specimens, the authors performed stepwise focused dissections of the lateral cerebral aspect to delineate the correlative anatomy between the SLF-I and the other two SLF subcomponents, namely the SLF-II and SLF-III.

RESULTS

The SLF-I was readily identified as a distinct fiber tract running within the cingulate or paracingulate gyrus and connecting the anterior cingulate cortex, the medial aspect of the superior frontal gyrus, the pre–supplementary motor area (pre-SMA), the SMA proper, the paracentral lobule, and the precuneus. With regard to the morphology of the SLF-I, two discrete segments were consistently recorded: an anterior and a posterior segment. A clear cleavage plane could be developed between the SLF-I and the cingulum, thus proving their structural integrity. Interestingly, no anatomical connection was revealed between the SLF-I and the SLF-II/SLF-III complex.

CONCLUSIONS

Study results provide novel and robust anatomical evidence on the topography, morphology, and subcortical architecture of the SLF-I. This fiber tract was consistently recorded as a distinct anatomical entity of the medial cerebral aspect, participating in the axonal connectivity of high-order paralimbic areas.

Mapping the superficial morphology of the occipital lobe: proposal of a universal nomenclature for clinical and anatomical use

The superficial anatomy of the occipital lobe has been described as irregular and highly complex. This notion mainly arises from the variability of the regional sulco-gyral architecture. Our aim was to investigate the prevalence, morphology, and correlative anatomy of the sulci and gyri of the occipital region in cadaveric specimens and to summarize the nomenclature used in the literature to describe these structures. To this end, 33 normal, adult, formalin-fixed hemispheres were studied. In addition, a review of the relevant literature was conducted with the aim to compare our findings with data from previous studies. Hence, in the lateral occipital surface, we recorded the lateral occipital sulcus and the intraoccipital sulcus in 100%, the anterior occipital sulcus in 24%, and the inferior occipital sulcus in 15% of cases. In the area of the occipital pole, we found the transverse occipital sulcus in 88% of cases, the lunate sulcus in 64%, the occipitopolar sulcus in 24%, and the retrocalcarine sulcus in 12% of specimens. In the medial occipital surface, the calcarine fissure and parieto-occipital sulcus were always present. Finally, the basal occipital surface was always indented by the posterior occipitotemporal and posterior collateral sulci. A sulcus not previously described in the literature was identified on the supero-lateral aspect of the occipital surface in 85% of cases. We named this sulcus "marginal occipital sulcus" after its specific topography. In this study, we offer a clear description of the occipital surface anatomy and further propose a standardized taxonomy for clinical and anatomical use.

The frontal longitudinal system as revealed through the fiber microdissection technique: structural evidence underpinning the direct connectivity of the prefrontal-premotor circuitry

OBJECTIVE

The purpose of this study was to investigate the morphology, connectivity, and correlative anatomy of the longitudinal group of fibers residing in the frontal area, which resemble the anterior extension of the superior longitudinal fasciculus (SLF) and were previously described as the frontal longitudinal system (FLS).

METHODS

Fifteen normal adult formalin-fixed cerebral hemispheres collected from cadavers were studied using the Klingler microdissection technique. Lateral to medial dissections were performed in a stepwise fashion starting from the frontal area and extending to the temporoparietal regions.

RESULTS

The FLS was consistently identified as a fiber pathway residing just under the superficial U-fibers of the middle frontal gyrus or middle frontal sulcus (when present) and extending as far as the frontal pole. The authors were able to record two different configurations: one consisting of two distinct, parallel, longitudinal fiber chains (13% of cases), and the other consisting of a single stem of fibers (87% of cases). The fiber chains' cortical terminations in the frontal and prefrontal area were also traced. More specifically, the FLS was always recorded to terminate in Brodmann areas 6, 46, 45, and 10 (premotor cortex, dorsolateral prefrontal cortex, pars triangularis, and frontal pole, respectively), whereas terminations in Brodmann areas 4 (primary motor cortex), 47 (pars orbitalis), and 9 were also encountered in some specimens. In relation to the SLF system, the FLS represented its anterior continuation in the majority of the hemispheres, whereas in a few cases it was recorded as a completely distinct tract. Interestingly, the FLS comprised shorter fibers that were recorded to interconnect exclusively frontal areas, thus exhibiting different fiber architecture when compared to the long fibers forming the SLF.

CONCLUSIONS

The current study provides consistent, focused, and robust evidence on the morphology, architecture, and correlative anatomy of the FLS. This fiber system participates in the axonal connectivity of the prefrontal-premotor cortices and allegedly subserves cognitive-motor functions. Based in the SLF hypersegmentation concept that has been advocated by previous authors, the FLS should be approached as a distinct frontal segment within the superior longitudinal system.

Defining the relationship of the optic radiation to the roof and floor of the ventricular atrium: a focused microanatomical study

OBJECTIVE

The authors investigated the specific topographic relationship of the optic radiation fibers to the roof and floor of the ventricular atrium because the current literature is ambiguous.

METHODS

Thirty-five normal, adult, formalin-fixed cerebral hemispheres and 30 focused MRI slices at the level of the atrium were included in the study. The correlative anatomy of the optic radiation with regard to the atrial roof and floor was investigated in 15 specimens, each through focused fiber microdissections. The remaining 5 hemispheres were explored with particular emphasis on the trajectory of the collateral sulcus in relation to the floor of the atrium. In addition, the trajectory of the collateral sulcus was evaluated in 30 MRI scans.

RESULTS

The atrial roof was observed to be devoid of optic radiations in all studied hemispheres, whereas the atrial floor was seen to harbor optic fibers on its lateral part. Moreover, the trajectory of the intraparietal sulcus, when followed, was always seen to correspond to the roof of the atrium, thus avoiding the optic pathway, whereas that of the collateral sulcus was found to lead to either the lateral atrial floor or outside the ventricle in 88% of the cases, therefore hitting the visual pathway.

CONCLUSIONS

Operative corridors accessing the ventricular atrium should be carefully tailored through detailed preoperative planning and effective use of intraoperative navigation to increase patient safety and enhance the surgeon's maneuverability. The authors strongly emphasize the significance of accurate anatomical knowledge.

Parietal association deficits in patients harboring parietal lobe gliomas: a prospective study

OBJECTIVE

Although the parietal lobe is a common site for glioma formation, current literature is scarce, consists of retrospective studies, and lacks consistency with regard to the incidence, nature, and severity of parietal association deficits (PADs). The aim of this study was to assess the characteristics and incidence of PADs in patients suffering from parietal lobe gliomas through a prospective study and a battery of comprehensive neuropsychological tests.

METHODS

Between 2012 and 2016 the authors recruited 38 patients with glioma confined in the parietal lobe. Patients were examined for primary and secondary association deficits with a dedicated battery of neuropsychological tests. The PADs were grouped into 5 categories: visuospatial attention, gnosis, praxis, upper-limb coordination, and language. For descriptive analysis tumors were divided into high- and low-grade gliomas and also according to patient age and tumor size.

RESULTS

Parietal association deficits were elicited in 80% of patients, thus being more common than primary deficits (50%). Apraxia was the most common PAD (47.4%), followed by anomic aphasia and subcomponents of Gerstmann's syndrome (34.2% each). Other deficits such as hemineglect, stereoagnosia, extinction, and visuomotor ataxia were also detected, albeit at lower rates. There was a statistically nonsignificant difference between PADs and sex (72.2% males, 85% females) and age (77.8% at ≤ 60 years, 80% at age > 60 years), but a statistically significant difference between the > 4 cm and the ≤ 4 cm diameter group (p = 0.02, 94.7% vs 63.2%, respectively). There was a tendency (p = 0.094) for low-grade gliomas to present with fewer PADs (50%) than high-grade gliomas (85.7%). Tumor laterality showed a strong correlation with hemineglect (p = 0.004, predilection for right hemisphere), anomia (p = 0.001), and Gerstmann's symptoms (p = 0.01); the last 2 deficits showed a left (dominant) hemispheric preponderance.

CONCLUSIONS

This is the first study to prospectively evaluate the incidence and nature of PADs in patients with parietal gliomas. It could be that the current literature may have underestimated the true incidence of deficits. Dedicated neuropsychological examination detects a high frequency of PADs, the most common being apraxia, followed by anomia and subcomponents of Gerstmann's syndrome. Nevertheless, a direct correlation between the clinical deficit and its anatomical substrate is only possible to a limited extent, highlighting the need for intraoperative cortical and subcortical functional mapping.

Finger tapping and verbal fluency post-tap test improvement in INPH: its value in differential diagnosis and shunt-treatment outcomes prognosis

BACKGROUND

Idiopathic normal pressure hydrocephalus (INPH) diagnosis is challenging as it can be mimicked by other neurological conditions, such as neurodegenerative dementia and motor syndromes. Additionally, outcomes after lumbar puncture (LP) tap test and shunt treatment may vary due to the lack of a common protocol in INPH assessment. The present study aimed to assess whether a post-LP test amelioration of frontal cognitive dysfunctions, characterizing this syndrome, can differentiate INPH from similar neurological conditions and whether this improvement can predict INPH post-shunt outcomes.

METHOD

Seventy-one consecutive patients referred for INPH suspicion and LP testing, were enrolled. According to the consensus guidelines criteria, 29 patients were diagnosed as INPH and 42 were assigned an alternative diagnosis (INPH-like group) after reviewing clinical, neuropsychological and imaging data, and before LP results. A comprehensive neuropsychological assessment for frontal executive, upper extremity fine motor functions, aphasias, apraxias, agnosias and gait evaluation were administered at baseline. Executive, fine motor functions and gait were re-examined post-LP test in all patients and post-shunt placement in INPH patients.

RESULTS

Of the INPH patients, 86.2% showed cognitive amelioration in the post-LP test; in addition, all but one (97%) presented with neurocognitive and gait improvement post-shunt. Verbal phonological fluency and finger tapping task post-LP improvement predicted positive clinical outcome post-shunt. None of the INPH-like group presented with neurocognitive improvement post-LP.

CONCLUSIONS

Post-LP amelioration of verbal fluency and finger tapping deficits can differentiate INPH from similar disorders and predict positive post-shunt clinical outcome in INPH. This becomes of great importance when gait assessment is difficult to perform in clinical practice.

Approaching the Atrium Through the Intraparietal Sulcus: Mapping the Sulcal Morphology and Correlating the Surgical Corridor to Underlying Fiber Tracts

BACKROUND: Although the operative corridor used during the intraparietal transsulcal approach to the atrium has been previously investigated, most anatomical studies focus on its relationship to the optic radiations.

OBJECTIVE: To study the intraparietal sulcus (IPS) morphology and to explore the subcortical anatomy with regard to the surgical trajectory used during the intraparietal transsulcal tranventricular approach.

METHODS: Twenty-five adult, formalin fixed, cerebral hemispheres were investigated. Fifteen underwent the Klingler procedure and were dissected in a lateromedial direction using the fiber microdissection technique. The trajectory of the dissection resembled that of real operative settings. The remaining 10 hemispheres were cut along the longitudinal axis of the sulcus in order to correlate its surface anatomy to corresponding parts of the ventricular system.

RESULTS: IPS demonstrated an interrupted course in 36% of the specimens while its branching pattern was variable. The sulcus anterior half was found to overly the atrium in all occasions. Four discrete, consecutive white matter layers were identified en route to the atrium, ie, the arcuate fibers, the arcuate segment of the superior longitudinal fasciculus, the corona radiata and tapetum, with the arcuate segment being near to the dissection trajectory.

CONCLUSION: Given the angle of brain transgression during the intraparietal approach, we found the optimal dissection area to be the very middle of the sulcus. The IPS–postcentral sulcus meeting point, in contrast to previous thought, proved to risk potential injury to the arcuate segment of the superior longitudinal fasciculus, thus affecting surgical outcome.

Efficacy, complications and cost of surgical interventions for idiopathic intracranial hypertension: a systematic review of the literature

BACKGROUND

To define the efficacy, complication profile and cost of surgical options for treating idiopathic intracranial hypertension (IIH) with respect to the following endpoints: vision and headache improvement, normal CSF pressure restoration, papilloedema resolution, relapse rate, operative complications, cost of intervention and quality of life.

METHODS

A systematic review of the surgical treatment of IIH was carried out. Cochrane Library, MEDLINE and EMBASE databases were systematically searched from 1985 to 2014 to identify all relevant manuscripts written in English. Additional studies were identified by searching the references of retrieved papers and relative narrative reviews.

RESULTS

Forty-one (41) studies were included (36 case series and 5 case reports), totalling 728 patients. Three hundred forty-one patients were treated with optic nerve sheath fenestration (ONSF), 128 patients with lumboperitoneal shunting (LPS), 72 patients with ventriculoperitoneal shunting (VPS), 155 patients with venous sinus stenting and 32 patients with bariatric surgery. ONSF showed considerable efficacy in vision improvement, while CSF shunting had a superior headache response. Venous sinus stenting demonstrated satisfactory results in both vision and headache improvement along with the best complication profile and low relapse rate, but longer follow-up periods are needed. The complication rate of bariatric surgery was high when compared to other interventions and visual outcomes have not been reported adequately. ONSF had the lowest cost.

CONCLUSIONS

No surgical modality proved to be clearly superior to any other in IIH management. However, in certain contexts, a given approach appears more justified. Therefore, a treatment algorithm has been formulated, based on the extracted evidence of this review. The traditional treatment paradigm may need to be re-examined with sinus stenting as a first-line treatment modality.

Effects of intracranial meningioma location, size, and surgery on neurocognitive functions: a 3-year prospective study

OBJECT Current recommendations stress the need for cognitive parameters to be integrated in the evaluation of outcomes for intracranial meningioma surgery. The aim of this prospective study was to examine neurocognitive function in meningioma patients pre- and postoperatively. METHODS Patients with skull base (anterior and middle fossa) and convexity (anterior and posterior) meningiomas (n = 54) underwent neuropsychological examination prior to and 1 year after surgery. A control group (n = 52) of healthy volunteers matched for age, sex, and education underwent the same examination. Assessments included executive, memory, and motor functions with standardized testing. Patients with convexity meningiomas were clinically assessed for parietal association cortex functions. RESULTS All patients performed significantly worse (p < 0.05) in most neurocognitive domains than controls. The skull base group showed more disturbances in memory than the convexity group (p < 0.05). The anterior convexity group showed more deficits in executive function than the posterior convexity group, which presented with parietal association cortex deficits. Verbal deficits were more pronounced in the left hemisphere than in the right hemisphere. Patients with a large tumor (> 4 cm) had more severe neurocognitive deficits than those with a small tumor (< 4 cm). Postoperatively, patients showed no deterioration in neurocognitive function. Instead, significant improvement (p < 0.05) was observed in some executive, motor, and parietal association cortex functions. CONCLUSIONS According to the authors' findings, intracranial meningiomas may cause neurocognitive deficits in patients. Surgery does not cause a deterioration in cognitive function; instead, it may lead to improvements in some functions. Permanent neuropsychological postoperative deficits should be interpreted as tumor-induced rather than due to surgery.

The cerebral isthmus: fiber tract anatomy, functional significance, and surgical considerations

OBJECTIVE

The cerebral isthmus is the white matter area located between the periinsular sulcus and the lateral ventricle. Studies demonstrating the fiber tract and topographic anatomy of this entity are lacking in current neurosurgical literature. Hence, the authors' primary aim was to describe the microsurgical white matter anatomy of the cerebral isthmus by using the fiber dissection technique, and they discuss its functional significance. In addition, they sought to investigate its possible surgical utility in approaching lesions located in or adjacent to the lateral ventricle.

METHODS

This study was divided into 2 parts and included 30 formalin-fixed cerebral hemispheres, 5 of which were injected with colored silicone. In the first part, 15 uncolored specimens underwent the Klinger's procedure and were dissected in a lateromedial direction at the level of the superior, inferior, and anterior isthmuses, and 10 were used for coronal and axial cuts. In the second part, the injected specimens were used to investigate the surgical significance of the superior isthmus in accessing the frontal horn of the lateral ventricle.

RESULTS

The microsurgical anatomy of the anterior, superior, and inferior cerebral isthmuses was carefully studied and recorded both in terms of topographic and fiber tract anatomy. In addition, the potential role of the proximal part of the superior isthmus as an alternative safe surgical corridor to the anterior part of the lateral ventricle was investigated.

CONCLUSIONS

Using the fiber dissection technique along with coronal and axial cuts in cadaveric brain specimens remains a cornerstone in the acquisition of thorough anatomical knowledge of narrow white matter areas such as the cerebral isthmus. The surgical significance of the superior isthmus in approaching the frontal horn of the lateral ventricle is stressed, but further studies must be carried out to elucidate its role in ventricular surgery.

Neuropsychological examination detects post-operative complications in idiopathic normal pressure hydrocephalus (iNPH): report of two cases

Subdural fluid collections (SFC) are characteristic complications of shunting for idiopathic normal pressure hydrocephalus (iNPH). This report presents two shunted iNPH patients with clinically silent postoperative SFC, detected after abnormal neuropsychological findings. These cases highlight the value of neuropsychological assessment in the routine postoperative assessment of iNPH.