VOLUME 24 • NUMBER 11

June 1, 2002

A BIWEEKLY PUBLICATION FOR CLINICAL NEUROSURGICAL

CONTINUING MEDICAL EDUCATION

Look for Free CD With Next Issue

Lippincott Williams & Wilkins, with the support of AESCULAP, has produced a CD on opening of the sylvian fissure that will be
included with volume 24, number 12 of Contemporary Neurosurgery. The CD will feature surgery by Professor M. Gazi Yaşargil,
M.D., edited by Ali F. Krisht, M.D.

Microsurgery of Insular Gliomas

Part I: Surgical Anatomy of the Sylvian Cistern
M. Gazi Yaşargil, M.D., Ali F. Krisht, M.D., Ugur Türe, M.D., Ossama Al-Mefty,
M.D., and Dianne C.H. Yaşargil, R.N.
Learning Objectives: After reading this article, the participant should be able to:
1. Recall the surgical anatomy of the sylvian fissure.
2. Recall the surgical anatomy of the middle cerebral artery and its variants within the sylvian fissure.

At the present time, the sylvian cistern can be precisely

and successfully explored, either partially or along the
entire length, avoiding injury to adjacent vital structures
and thus preserving their functions. Depending on the
topography and extensions of the lesions, the surgical
opening of the sylvian cistern is accomplished either only
in the promixal or middle section or in the entire length
of the fissure.
This publication in four parts is dedicated to the surgi-
cal treatment of the insular gliomas. Therefore, the micro-
surgical opening of the entire sylvian cistern and exploration
of entire sylvian fossa is described.

Surgical Anatomy of the Sylvian Cistern A

The sylvian cistern comprises three distinct parts,
namely the fissure, opercular sulci, and the fossa (Fig. 1A Figure 1A. Schematic drawing of the sylvian cistern with its distinct
and B). three parts, namely fissure, inter-opercular sulcus, and fossa. S, supe-
rior; I, inferior pouches of the sylvian fossa; Put., putamen.

Dr. Yaşargil is Professor, Dr. Krisht is Associate Professor, Dr. Al-

Mefty is Professor, Mrs. Yaşargil is Research Instructor, Depart-
ment of Neurosurgery, University of Arkansas for Medical Sciences,
4301 West Markham, Slot #507, Little Rock, AR 72205; and Dr. Türe
is Associate Professor, Department of Neurosurgery, Marmara
University School of Medicine, Istanbul.
The authors have disclosed that they have no significant rela-
tionships with or financial interests in any commercial organiza-
tions pertaining to this educational activity.
The Sylvian Fissure
The sylvian fissure is a long (10–14 cm) division between
fronto-orbital, frontal perietal, and temporal opercula. The syl-
vian fissure is divided into two sections:
Category: Tumor
Key Words: Microsurgery, Glioma, Insula, Anatomy, Sylvian fissure

B thin, and fragile or even tough pial fibers form a dense net-
Figure 1B. Left-sided cerebral-cerebellar hemispheres. Topography
of the sylvian fissure. Pr, proximal segment; Di, distal segment.
The proximal section, also named the sylvian stem or hor-
izontal–anterior–medial–sphenoidal limb, is located between
the high bifurcation of the ICA and the pars triangularis of
the inferior frontal gyrus (F3), where the basal fronto-orbital
surface curves to the dorsal surface of the frontal brain (syl-
vian point). The configuration of the proximal section, which
is 30 to 50 mm in length, rarely follows a straight line. Often
the lateral orbital gyrus indents markedly laterally and com-
presses the area of temporal pole or proximal segment of
the superior temporal gyrus, causing a C- or S-shaped course
of the proximal fissure.
The distal section of the sulcus, also named the lateral
or posterior limb, extends from the sylvian point to the
supramarginal gyrus, measures 6 to 9 cm in length, and
courses in a slightly or moderately undulating line due to
indentations of the frontal, parietal, and temporal gyri into
the sulcus.
The sylvian fissure is covered along its entire length with
a superficial arachnoid membrane, which may be very fine
and transparent or extremely thick and opaque. The 5- to
6-mm-wide membrane covers the sylvian vein(s) and is
scarcely adherent to these veins.
The Inter-Opercular Sulci
Aside from well-described branches of the sylvian fis-
sure, such as the horizontal, ascending rami, diagonal, ante-
rior, and posterior subcentral, posterior temporal sulci and
their variation (see publication of Ono et al.), there are inter-
opercular sulci, which until now have not been described
according to their particular surgical significance.
The sylvian fissure is intercepted by several inter-oper-
cular sulci, which are located between the opercular sur-
faces of the lateral orbital, inferior frontal, inferior parietal
and opercular surface of superior temporal gyrus. These
sulci are usually oblique and curved due to the indenta-
tions of the opponent gyri (see Fig. 2A). Numerous short,
work within these very narrow (0.1–0.3mm) sulci. This ren-
ders dissection of the sylvian fissure more difficult,
demanding patience and skill from the surgeon.
In the proximal part of the fissure between posterior
medial orbital, posterior orbital, posterolateral orbital and
suborbital gyri and temporal pole, polar planum, and
Schwalbe gyri (see Fig. 2 in the article by Türe et al: J Neu-
rosurg 90:723, 1999), the depth of the inter-opercular sulci
is 10–20 mm. In the middle section of the sylvian fissure,
between subtriangular, subopercular, subprecentral gyri
and the opponent parts of the superior temporal gyrus, the
depth of the inter-opercular sulci increases to 25–40 mm.
In the distal part of the sylvian fissure, between the subcen-
tral, the anterior, middle, and posterior transverse gyri of the
inferior parietal lobe and the anterior and posterior transverse
gyri (Heschl) and temporal planum (postinsular sulcus), the
depth of the inter-opercular sulci increased even more, to 35–50
mm. To achieve precise exploration of the sylvian fossa, the
middle cerebral artery (MCA) and its branches, and the insu-
lar and opercular veins (during the exploration of insular tumors,
AVMs, or cavernomas) requires us to surmount the obstacle
presented by the delicate structuring of the intra-opercular sulci
(see Figs. 2A and 8).
Applying meticulous microneurosurgical techniques and
detailed anatomic knowledge of the particular and intri-
cate anatomy of the sylvian cistern, the fissure, including

EDITOR: Ali F. Krisht, M.D.* The continuing education activity in Contemporary Neurosurgery is intended for neurosurgeons, neurologists, neu-
University of Arkansas for Medical Sciences roradiologists, and neuropathologists.
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2
 Sulcus
Sulcus

Sulcus

Figure 2A. Sections of the sylvian fossa with a variety of inter-opercular sulci along the fissure.

interopercular sulci, can be opened completely, avoiding
damage to the vessels and to normal brain structures.
The Sylvian Fossa
The sylvian fossa, hidden beneath the opercula, consists
of three sections (Fig. 2 A–C).
The proximal section is located between the bifurcation of
ICA and limen insula, where the MCA bifurcates into the
superior and inferior trunks. It measures 30 to 39 mm in
length and 5 to 6 mm in width, and is named by anatomists
“Vallecula” or preinsular sulcus (see Fig. 2B). Coursing
within are M1 segments of MCA, the extracerebral lateral

3
B C
Figure 2B. Fully spread vallecula on a rubberized left cerebral
hemisphere. Li, limen insula. The left panel shows the region of
the vallecula highlighted.
lenticulostriate arteries, deep sylvian vein, and, occasion-
ally, M2 segments, which may originate in the proximal or
middle part of the M1 segment. The vallecula is covered
laterally by the proximal medial part of the superior tem-
poral gyrus (polar planum), and medially by the lateral
orbital gyrus, which may protrude and cause an indenta-
tion in the middle portion of the vallecula as far as the tem-
poral area. In these instances, this section of the sylvian
sulcus is a curving C or S shape.
The middle (insular) section of the sylvian fossa demonstrates
a sizeable component: 6 to 7 cm in length, 5 to 6 cm in width,
and 3 to 5 mm in depth, and it extends from the level of the
limen insula to the posterior insular point. The extension of
the fossa underneath the opercula creates four pouches. The
anterior pouch extends beneath the lateral orbital gyrus to the
anterior peri-insular sulcus, the superior pouch extends beneath
the frontal operculum to the superior peri-insular sulcus, the
posterior inferior pouch extends beneath the parietal opercu-
lum to the retroinsular fossa (postinsular sulcus) and the infe-
rior pouch extends beneath the temporal operculum to the
inferior peri-insular sulcus (see Fig. 2C).
Three to five short and two long insular gyri are located
at the base of the insular fossa. The external perimeter of
this group of gyri is delineated by peri-insular sulci.
The retroinsular fossa (or postinsular sulcus) is short but
deep (4–5 cm), covered by the supramarginal gyrus, the trans-
verse temporal gyri (Heschl), and transverse parietal gyri,
and it contains the arteries of the M3 segment (anterior and
posterior parietal, supramarginal, and angular gyrus and
occipitotemporal artery), which course and curve around the
parietal and temporal opercula to the surface (see Fig. 2C).
Along all these sections of the sylvian fossa, a dense net-
work, occasionally even a membraneous structure, of
pial–arachnoidal fibers intervene arteries, veins, and pial
surfaces of the adjacent opercular and insular gyri.
Surgical Anatomy of the Middle Cerebral Artery
Numerous publications deal with the anatomy and radio-
logic anatomy of the MCA. The excellent studies of Krayenbühl
4
Figure 2C. Sylvian fissure and fossa after fully opening the inter-
opercular sulci. Fully spread sylvian fossa on a rubberized left cere-
bral hemisphere, which shows well the triangular-shaped insula, the
anterior, superior, and inferior peri-insular sulci, retroinsular fossa,
and postinsular sulcus, as well as the hidden parts of operculum.
and Yaşargil (1965), Teal et al. (1973), Ring (1973), Waddington
(1974), Salamon and Huang (1976), Szikla et al. (1977), Grand
(1980), Gibo et al. (1981), Umansky et al. (1988), Marinkovic (1997),
Komiyama et al. (1998), Türe et al. (2000) and the surgical obser-
vations of the senior author are summarized as follows:
M1 Segment
The course of the M1 segment (3–4 cm in length) does not
always follow a straight, descending diagonal line along the
proximal sylvian fossa (vallecula), but it may take an undu-
lating C- or S-shaped route (Fig. 3A–D). Furthermore, in 10%
of cases, the M1 segment make a significant curve posteriorly
and can be obscured by the arch of limen insula (Fig. 4B). In
40% of cases, the M1 segment makes a significant curve ante-
riorly (Fig. 4C), and in 1% of cases, double anterior curves
(Fig. 4D). The proximal part of the M1 segment is rarely
(0.1%–0.3%) fenestrated. In the literature, a duplication of the
M1 segment is found in 0.3% to 3.0% of cases. At surgical
exploration, two, three, or even four arteries, equal in size,
coursing parallel to each other along the proximal sylvian
fossa, may be identified. This perplexing configuration can
be resolved by further exploring these arteries proximally as
far as the internal carotid artery (ICA) bifurcation, which
reveals that this particular situation is related to the fact that
the temporal arteries (pole, anterior, middle, and posterior
temporal arteries) arose as a common trunk from the proxi-
mal or middle lateral wall of the M1 segment. This early tem-
poral bifurcation occurs in 10% of cases (Fig. 5A). In a further
8% of cases, the frontal arteries (temporal fronto-orbital, pre-
frontal, and precentral arteries) arise as a common trunk from
the medial wall of the M1 segment. This is frontal early bifur-
cation (Fig. 5B). In 2% of cases, both types of common trunks
originated from the M1 segment (Fig. 5C). Such unusual
occurrences give the impression of a true duplication of the
M1 segment. Another issue is the occasional (in 0.5%) pres-
ence of an accessory MCA, which originates from a proximal
or distal A1 segment (Fig. 5D), and which also can imitate a
true duplication of the M1 segment. Four arteries are found
in a combined variation such as that shown in Figure 5E.
 ICA

ACA

MCA
(M1)

Straight Diagonal C-shaped Temporal C-shaped Frontal S-shaped

A B C D
Figure 3. A–D, Course variation of the left M1 segment in the horizontal plane. (Surgical view of left side.)

Straight Diagonal Posterior Course Anterior Course Double Loop

Ascending 10% 40% 1%

A B C D
Figure 4. A–D, Course variation of the left M1 segment in the vertical plane. (Surgical view of left side.)

Early Bifurcation Early Bifurcation Early Bifurcation Accessory MCA Four Arteries in
(Temporal 10%) (Frontal 8%) (Temp. & Front. 2%) (0.5%) the Vallecula (0.1%)
A B C D E
Figure 5. Schematic illustration of the branching variation of left M1 segment. (Surgical view of left side.) A, Common trunk of temporal
arteries arising from proximal or middle part of M1 segment (temporal early bifurcation). B, Common trunk of frontal arteries arising from
medial wall of the M1 segment (frontal early bifurcation). C, Two common trunks arising from proximal or middle part of M1 segment (early
pseudo-bifurcation) (2%). D, Accessory MCA can imitate a double M1 segment (0.5%). E, Early pseudo-bifurcation and accessory MCA
imitate four M1 segments (0.1%).

5
M2 Segment
In 50% of cases, the M1 segment divides into superior and
inferior M2 trunks, usually at the level of the limen insula
(Fig. 6B). In 2% of cases, the M1 segment does not divide; it
continues as a single trunk along the entire length of the syl-
vian fossa and consistently branches to the frontal, parietal,
and temporal areas (Fig. 6A)
In 15% of cases, the superior M2 trunk and in a further
10% of cases the inferior M2 trunk divide again in close prox-
imity of the M1 bifurcation, which is diagnosed on
angiograms as a trifurcation (Fig. 6D, E). In 5% of cases, both
superior and inferior M2 trunks divide in close proximity to
the M1 bifurcation, which gives the impression of a tetra-
furcation (Fig. 6C). It is important to recognize that not just
two, but three or even four M2 trunks may be present, namely
superior, middle, and inferior trunks, which supply, with
their branches, in a consistent and regular pattern the frontal,
parietal, temporal, and lateral temporo-occpital areas.
The lateral fronto-orbital and prefrontal branches may
arise from M1 or superior M2 trunks. The precentral,
central, anterior, and posterior parietal arteries may arise
either from a superior trunk (60%) or from a middle
(25%) or inferior trunk (15%) (Figs. 6D–F and 7).
The superior M2 trunk does not give any branches to the
temporal lobe; on the contrary, the middle and inferior
trunks give branches to both the temporal and parietal areas
(see Fig. 6).
The branches of the superior and middle trunks course over
the insular gyri or along the insular sulci into the anterior and
superior pouches (limbs) of the sylvian sulcus (Fig. 7). At the
level of the anterior and superior peri-insular gyri and within
retroinsular fossa, these branches angle 180 degrees and follow

No bifurcation Superior and inferior Pseudo-tetrabifurcation 5%,

(single M2 trunk 2%) trunk are symmetrical four M2 segments
A B C
Figure 6 A–C. Variations of MCA divisions. (Surgical view of left side.) A, No bifurcation, simple trunk (2%). B, Classical bifurcation with
superior and inferior trunks (50%). C, Pseudo-tetrabifurcation: early divisions of superior and inferior trunks create a four trunks (5%).

Pseudo-trifurcation, three M2 trunks Pseudo-trifurcation, three M2 trunks Inferior trunk supply, three M2 trunks
(middle trunk from temporal side 10%) (middle trunk from frontal side 15%) Centro–parietal region 15%
D E F
Figure 6 D–F. (Surgical view of left side.) D, Pseudo-bifurcation of MCA with early branching of middle trunk from inferior trunks (10%).
E, Pseudo-bifurcation of MCA with early branching of middle trunk from superior trunk (15%). F, Inferior trunk gives branches to the
centro-parietal areas (15%).
6

Figure 7. Schematic illustration of the M1–M4 segment, in coro-
nary view, left side. H, Heubner artery; Lst, lenticulostriate arteries.
Figure 8. Course of the M2–M4 branches within the sylvian fossa and around the opercula.
Readings
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internal carotid artery bifurcation. Neurosurgery 22:1023, 1980
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mislabeled cranial landmark. J Ultrasound Med 3:15, 1984
7
a return course beneath the opercula as the M3 segment, pass
through the narrow sylvian fissure, and curve 180 degrees
around the opercula, reaching the lateral surface of frontal and
parietal lobes as M4 segments (see Fig. 7).
These arteries, as M5 branches, continue over the gyral
surfaces or are hidden in the depth of sulci to the areas of
middle frontal gyrus, pre- and post-central gyri, and supe-
rior parietal lobe, where they may conncet to the A5 branches
of the anterior cerebral artery.
The inferior M2 trunk courses into the inferior pouch
(limb) of the sylvian fossa beneath the temporal opercula,
and gives anterior, middle, posterior, and temporo-occipi-
tal arteries, which pass the sylvian fissure beneath the tem-
poral operculum as M3 segments, reaching the surface of
the temporal lobe as M4 segments.
In 15% of cases, the inferior trunk gives branches to the
pre- and postcentral and parietal areas (Fig.8). They course
diagonally across the sylvian fossa to reach the superior
and posterior pouches of the sylvian fossa, returning around
the operculum to the lateral surface.
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1. The proximal section of the sylvian fissure has a C- or S- 6. The M3 branches of the middle cerebral artery extend from
shaped configuration and rarely a straight line. the sylvian fossa to the sylvian fissure.
True or False? True or False?
2. The distal section of the sylvian fissure extends from the syl- 7. An anterior course of the middle cerebral artery is seen in up
vian point to the supramarginal gyrus. to 40% of cases.
True or False? True or False?
3. The vallecula is the proximal part of the sylvian fossa.
8. The superior M2 trunk gives branches to the temporal lobe.
True or False?
True or False?
4. Early bifurcation of a dominant temporal branch occurs in
10% of cases. 9. M4 branches are distal to the sylvian fissure.

True or False? True or False?

5. The division of the M1 into two equal trunks (superior and 10. The middle (insular) section of the sylvian fossa has extensions
inferior) occurs in 90% of cases. into four pouches (anterior, posterior, superior, and inferior).
True or False? True or False?