Downloaded from www.ajronline.org by 92.83.162.251 on 11/29/22 from IP address 92.83.162.251. Copyright ARRS.

For personal use only; all rights reserved

Pictorial Essay
The Hippocampus: Normal Anatomy and Pathology
L AnneHayman1,
GregoryN.Fuller2,José
E.Cavazos3,
MarkJ. Pfleger4,
ChristinaA.Meyers5,EdwardF.Jackson6

T he hippocampi are unique and vital
regions found in each of the cere
bral hemispheres. In most subjects,
the dominant left hippocampus primarily medi
ates verbal learning and memory, whereasthe
nondominant right side primarily mediates non
verbal memory. Becausebilateral hippocampal
lesionsresult in amnesia(i.e., inability to learn
new information), extensive hippocampal re
search has been undertaken. The advent of sur
orly, it becomes the cingulate gyms; anteroinfe tenor tail. In humans, this gyms continues as
riorly, it becomesthe paraterniinal gyms. The the vestigial supracallosalgyrus (indusium gri
smaller, inner limbic gyms contains the hip seum), and anteroinferiorly it is renamed the
pocampus, which is subdivided into three seg vestigial paraterminalgyms.
ments: the bulbous anterior head (also called Anatomic coronal sections are traditionally
the pesor foot), the body, and the slenderpos shownonly at the mid body ofthe hippocampus
@J).

gical procedures that can cure medically

intractableseizuresby excisionof hippocampal t frur@;)- .@“-.
abnormalities also has spurred extensive re
@ search directed toward MR analysis of this re Paraterminal
gyros - Parahippocampal
gyrue
gion. Our purpose is to introduce the reader to
these techniques. This paper is divided into @. , Vesti@ supracallosal
‘¿ .. - -. gyms (induseum griseum)
three parts: normal hippocampal anatomy, MR
@ imaging techniques,andrefractoryepilepsy. :. ,@ Tail

Normal Hippocampal Anatomy

The limbic lobe is formed by two gyri on the Vestigialparaterminalgyros Body
medial surface of each cerebral hemisphere. Head(foot,pes)
The larger outer gyms is renamed as it encircles
the corpus callosum (Fig. 1). Posteroinferiorly, Fig.1.—Limbic
lobeanatomy.
Drawings
showsubdivisions
ofouterandinner
it is calledthe parahippocampal gyrus;superi limbiclobegyri.

ReceivedJanuary22,1998;acceptedafterrevisionMarch10,1998.
1Department of Radiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030-3498. Address correspondence to L A. Hayman.

2 Department of Neuropathology, University ofTexas M. D. Anderson Cancer Center, Houston, TX 77030.

3Departmentof Neurology,Universityof ColoradoHealthSciencesCenter,Denver,CO80262.

4Departmentof Radiology,OverlakeMedicalCenter,Bellevue,WA98004.
5 Department of Neuro-oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX 77030.

tDepartmentof DiagnosticRadiology,UniversityofTexasM. D.AndersonCancerCenter,Houston,TX77030.

AJR1998;171:1
139—1
1460361—803X/98/1714—1
139©AmericanRoentgenRaySociety

AJR:171,October1998 1139
 Hayman et al.

I
e
m
Temporal Horn
p
Downloaded from www.ajronline.org by 92.83.162.251 on 11/29/22 from IP address 92.83.162.251. Copyright ARRS. For personal use only; all rights reserved

. . .

C A
@ m . . ;. ... .. . @. (Fusiform

@ S
b J@.. @. @: . \gyrus

@
e
r
n
e
n
t
..
/1'
I COLLATERAL SULCUS

H
Residual cleft with cyst in 10-20% of normals
0

n
—¿
Dentate
gyrus
(molecular
cell
layer)
CA = CORNUAMMONS(Ammon's horn)(pyramidalcell layer)
—¿
CAl
@ —¿
CA2 CA4
(end
folium)
A B
Fig.2.—Hippocampal
anatomy.
A,Drawing ofaxialsection
oflefthippocampus
seenfrombelowshowsrotation
ofhippocampusanditsrelationship
withdentate
gyrus.
(Modifiedwithpermissionfrom11])
B,Drawingofcoronalsectionatmidbodyoflefthippocampus
showscross-sectional
relationship
betweenhippocampusandsurrounding
structures.
(Modifiedwithpermis
sionfrom [41)

(Fig. 2) 11—5].
At this level, it consistsof two in
terlocking laminae of gray matter: the cornu
ammonis (Ammon's horn) and the dentategy
flis. The comu ammonis can be divided into
four microscopic zones of granular cells:
CAl, CA2, CA3, and CA4 (Fig. 2). This
coronal section simplifies the complexity of
these cellular layers and makes this location
ideal for evaluating the hippocampus. There
fore, hippocampal imaging is described in
coronal sections that are perpendicular to the
long axis of the temporal horn. However, even
high-field-strength I .5-T MR imaging shows
little of the cellular anatomy (Fig. 3). Rather,
it defines the outline of the three major fis
sures: hippocampal, fimbriodentate, and chor
oidal, which allows the reader to infer the
location of the cellular anatomy. The hippo
campal sulcus (fissure) is presentin the head,
body, and tail of the hippocampus.Anteriorly,
this fissure merges with the uncal sulcus [ 1].
The hippocampal sulcus (fissure) is usually
obliterated laterally in utero and may not be
visualized (or only a small portion is visible).
The hippocampal sulcus is found between the
dentate gyrus and the subiculum and cornu
ammonis. Small remnants of the hippocampal
sulcus (fissure) should not be mistaken as pa
thology. Figures 4—6show all of the fissures,
the cellular anatomy of the hippocampus, and
its surrounding structures on colored serial
coronal myelin-stained sections and on com
panion serial T2-weighted MR images.

@ k: :i Ch@

@ B

Fig.3.—Normal
coronalhippocampus in24-year-oldman.
A,Fastspin-echo12-weighted MRimagethrough bellyofponsshowschoroidal fissure(Ch),fimbriodentate
fissure(FD),andhippocampal sulci(H)(fissures)
onleft(also
seeFig.8A).Notethatsmallcysticresidualoffetalhippocampalsulcus(fissure)isseenonbothsides.
B,Fastspin-echo12-weightedMRimagethroughmiddlecerebellarpeduncleshowscontinuation ofthreemajorhippocampal sulci(fissures).Ch=choroidalfissure,
FD=fimbriodentatefissure,H =hippocampa)sulcus.Notesmallcysticresidualoffetalhippocampal sulcus(fissure)(solitaryarrowonrighthippocampus).

1140 AJR:171,October1998
Downloaded from www.ajronline.org by 92.83.162.251 on 11/29/22 from IP address 92.83.162.251. Copyright ARRS. For personal use only; all rights reserved

@,-#

@ . ,.

. —¿
Mama @arybodyd
Uncaf
:@ notch
(tertora@
@ r@press@on) S
@ Collateraf

C D

Choroidaf fia
- S Uncal guiCuS
r ‘¿@UncaI notch
.2 tentoraf
‘¿S Imoress;orr)

V Collateral
fissure
E
Dsntategynhs
—¿
—¿
entorhinal
area
(connects parahippocampus with CAl)

lanterlorparahlppocampalgyrus)

—¿
body
of
parahippocampal
gyrus
@ CA - @en.r
sictor) •¿ amygdala
Comu Ammonia
@ (Ammon's horn) :@:@.i.i“¿slat—It
zen.) gyms amblins
—¿
tail
of
parahippocampal
gyms
@
—¿ CM !.@::unaris —¿
vestigial
supracallosal
gyms
(becomes cingulate gyrusInot shown])

(induslum griseum)

Fig.4.—Normal
anatomyofamygdala
andhippocampal headonpairedserial,myelin-stained
coronalbrainsections
andcompanion
12-weightedMRimages.Bothmyelin-stained
sec
tionsandMRimagesareasymmetric,
causing
slightlydifferent
appearancebetween right-andleft-sided
structures,
whichproduces
sixuniquesections.
Colorkeyisguidetoimportant
structuresandlandmarks.
A,Myelin-stained
brainsectionimmediately
rostraltoheadofbothhippocampi.
B,CompanionMRimagerostraltohippocampishowsdivergingoptictract(Ot),sylvian
fissure(Sf),anduniquebranching
patternofwhitematterinrostraltemporal
lobeonrightRostral
amygdala(A)is seenonleft
C,Myelin-stained
brainsectionofanteriormost
lefthippocampal
headorpes(foot)showscornuammonis
zone1(CAl)belowtemporal
horn.Amygdala
(blue)persists
onrightbuthas
almostdisappearedonleftside.Uncus(pink)is seenaboveandmedialto bothamygdalae.Uncalnotchis postmortemartifact.
D,Companion MRimageshowsmamilothalamic tractsconvergingtositeofmamillary
bodies(Mb),sylvian
fissure(Sf),androstralrightamygdala
(A)asitfadesintouncus.Uncalrecess
(Ur)oftemporal
hornisseenonright(joinedarrows). UralsoisseeninE.
E,Myelin-stained
brainsectionofleftmidportionofhippocampal headorpes(foot)showsrelationshipofuncus(pink)toCAlcells(red).Notethatuncalextension oftemporal horn
seenonrightshouldnotbemistaken forpathology(Fig.10).Uncalsulcusisshownonleft CAlcellsseparateuncalsulcusfromuncalrecess.Righthippocampal headshowscompli
catedalternatingcellularrelationshipsof CAl (red),CA2(turquoise),andCA3(brightyellow)cellsto centrallylocatedamygdala(blue).CA4appearsin Figure5A.
1@
Companion
MRimageshowsinterpeduncularfossa
(If)between
cerebral
peduncles
andvessels
inambient
cistern(Ac)asitmerges
withchoroidalfissure
(Ch)andtemporal
horn(Th).
 .-

•¿\4

Al F I
A4
Downloaded from www.ajronline.org by 92.83.162.251 on 11/29/22 from IP address 92.83.162.251. Copyright ARRS. For personal use only; all rights reserved

4'

@
@
, @----@- Choroidal
fissure fissure
Collateral fissure

—¿
Dentate
gyrus —¿
@ CA = @imer
sector) amygdala
—¿
entorhina)
area(connects parahtppocampus with CAl)

anterior parahlppocampat gyrus)

Comu Ammonia
—¿
body
of
parah(ppocampai
gyms
@ (Ammon's horn) @@iaI
rsslstant zone) gy@u@ambiens
—¿
tao
of
parahippocampa)
gyms
@
—¿
(End
folium)
CA3 @:@7unaris
—¿
vestigial
supracaliosa)
gyrus
becomescingulategyrus[notshown])

)induslum griseum)

Fig.5.—Normal
anatomy
ofhippocampal
bodyonpairedserial,myelin-stained
coronalbrainsections
andcompanion
12-weighted
MRimages.
Bothmyelin-stained
sections
andMR
imagesareasymmetric,causingslightlydifferentappearancebetweenright-andleft-sidedstructures,which producessixuniquesections.Colorkeyis guideto importantstructures
andlandmarks.
A,Myelin-stained brainsectionofbothanteriorhippocampal bodieshasclassiccellularconfigurationofcornuammonis zone1(CAl,red),zone2(CA2, turquoise),
zone3(CA3,bright
yellow),andthesmallest zone4(CA4, magenta) showninFigure 2.Largeportionofuncus(pink)continues tobepresent onrightbuthasalmostdisappeared onleftside.
B,Companion MRimageshowshypointense whitematterofalveus(Al)andfimbria(F),whichseparate hippocampal cortexbelowfromsuperior brightsignalintensity
ofpartialvolume
ofCSFandchoroidal plexusinthintemporal horn.Hypocellular
molecular layerofdentategyrus(arrowheads) hashypointense signalintensity
thatissameasthatseeninwhitematter
elsewhere inbrain.Imageisconfusing because intervening
cellsofcornuammonis zone2(CA2, turquoise)anddentate fibers(darkgreen)that separate hypointensealveusabovefrom
hypointense molecularlayerbelow(A)arenotresolved and,therefore, hypointensity
appears ascontinuous band.
C,Myelin-stained brainsectionofhippocampal bodyissmallerversionofclassiccellularconfigurationshowninA andinFigure2.UncalsulcusseeninA hasbecome hippocampal
sulcus(fissure),
andfimbriodentatefissurehasappeared. Atthislevel,cellsofentorhinal
area(lightgreen2)havebeenreplaced bymainbodyofparahippocampal gyrus(lightgreen2a).
D,Companion MRimageshowspulvinar (Pul)ofthalamus,choroidalfissure(Ch),collateral
fissure(CoIl),
andtemporal horn(Th)entering atriumoflateralventricle.
E,Myelin-stainedbrainsectionoflastportionofhippocampal bodyatantenormost splenium ofcorpuscallosum.Bodyofparahippocampal gyrus(lightgreen2a),whichispresentin
previous sections,
islastseenonthislevel.ItisreplacedinFigure 6Abytailofparahippocampal gyrus(lightgreen3).
F,Companion MRimage shows spleniumISpI),caudatenucleus )Cn),
andcrusoffornix )Cfx).
 MR Imaging of the Hippocampus

@,if

* Sp:
Downloaded from www.ajronline.org by 92.83.162.251 on 11/29/22 from IP address 92.83.162.251. Copyright ARRS. For personal use only; all rights reserved

L @B
A

I
,@(tk,@@-
.‘

C D

—¿
Dentate
gynis —¿
@ CA @sn.r
sector) •¿ amygdaia
—¿
entorhinal
area(connects parahlppocampus with CAl)

(anterior parahippocampal gyrus)

ComuAmmonia
—¿
body
of
parahlppocampai
gyms
@ (Ammon'. horn) @@r@aI
nshetuit son.) gyi'tzs amblens
—¿
tail
of
parahippocampal
gyms
@ CA3 @::i@unai1s
—¿
vestigial
supracaiiosai
gyms
(becomes cingulate gyrus[not shown])

(indusiumgriseum)

Fig.6.—Normal
anatomyofhippocampal
tailonpairedserial,myelin-stained
coronalbrainsectionsandcompanion
12-weighted
MRimages.Bothmyelin-stained
sections
and MR imagesare asymmetric,causing slightly different appearancebetween right- and left-sided structures, which producesfour uniquesections. Colorkey is guide
to important structures and landmarks.
A,Myelin-stained
brainsectionofjunctionofbodyandhippocampal
tailbelowposteriorspleniumofcorpuscallosum.Cornuammonis
zone1(CAl)cells(red)predominate
and surround dentate gyrus (dark green).Gyrusfasciolaris is composedof CA3cells (yellow). Gyruscinerea is formed by CA4cells (magenta).Body of parahippocampal
gyrus (light green 2a in Figure5E)hasterminated, andtail of parahippocampalgyrus appears(light green 3). Collateralsulcus terminates at this level.
B,Companion MRimageshowsatriumof lateralventricle,anteriorcalcarinefissure(AC),andsplenium)Spl)of corpuscallosum.Alveus(Al)oftencanbeidentifiedbe
tweenbrightsignalintensityof CSFandcortexofcornuammonis zone1(CAl)hippocampal cells.
C,Myelin-stained
brainsectionofhippocampal tailcontainslastsmallremnantofcorpuscallosumbelowsupracallosal
gyrusonright.Anteriorcalcarinefissureseparates
cornu ammoniszones1 (CAl, red) and 3 (CA3,brightyellow) cellular layers of hippocampusfrom subiculum(light green 1).
D,Companion
MRimageshowsanteriorcalcarinefissure(AC).

MR lmagingTechniques
Clinical1-lippocompalImaging
High-field-strength MR ( I .5-T) scans are best
suited fbr detailed hippocampal studies. All im
ages must use window settings that optimize
gray—whitematter differentiation. Excellent
quality standard axial images of the brain must
be obtainedto detectconcurrentor separateab
normalities. However, the fbllowing coronal
scans of the hippocampus should also be ob-
tamed: fast spin-echo T2- and spin density
weighted images (two repetitions. 20- to 24-cm
field of view,256 x 256 matrix, 3- to 5-mm sec
tions with the smallest possible gap); and TI
weighted images (four repetitions, 16-cm field
of view, 3- to 5-mm contiguous sections). A Tl
weighted spoiled gradient-recalledecho in the
steadystate,inversionrecovery,or TI-weighted
fluid-attenuatedinversionrecoverysequencecan
beobtainedifthese capabilitiesareavailable[6].
Volumetric
Analysis
Over the last few years, more than 90 arti-
des have described MR volumetric analysis of
the limbic structures! Considerable disagree
ment exists relating to how to perform these
volumetric studiesand what the results mean.
Currently, these studies are impractical in the
routine clinical setting because highly trained
personnelmust trace the hippocampal outline.
The details of this procedure have been re
viewed recently [7].
Spectroscopy
MR spectroscopycan be usedto obtain non
invasive biochemical information in a living pa

AJR:171, October 1998 1143

 Hayman et al.

PC
Cr
Downloaded from www.ajronline.org by 92.83.162.251 on 11/29/22 from IP address 92.83.162.251. Copyright ARRS. For personal use only; all rights reserved

Cr

-,@. I,,., I

4 2 0
ppm
A B

Fig.7.—'HMRspectra.
A,Eightcubiccentimeters
ofnormal
frontoparietal
region.
Short-TE
(30msec)MRspectroscopy
showsgoodwatersuppression
andspectral
resolution
ofvarious
bio
chemicals.NAA= N-acetyl-L-aspartate,GABA=‘¿y-aminobutyric
acid, glu = glutamate,gIn= glutamine,asp= aspartate,PCr= phosphocreatine,Cr creatine, Cho= choline,
Ins= myo-inositol.
B,Fivecubiccentimetersof normalhippocampus.
Short-TE
(30msec)MRspectroscopy
showsbroaderspectralpeaksandpoorlydefinedbaselineresultingfromlocal
field inhomogeneitiesin region.Useof longerTE(>100msec)would significantly improvebaselineby increasingwater-suppressionefficiency. However,resulting spectral
information
wouldincludeonlyNAA,Cr,PCr,andChobecauseotherbiochemicals
haveshort12relaxationtimes.

. CAt2@

@ .,, / :‘@

@ . .. ., .. .p .
.,@ I

i@/P:,,:1@i1@::
A B

Fig.8.—Hippocampalsclerosis.
CAl=cornuammonis zone1.CA2= cornuammonis zone2.
A,Coronalsection ofbrainshowsnormal leftCA2andsevereatrophy ofleftCAlwithflattening
ofnormal
hippocampal bulgeintotemporalhorn(curvedarrow)(seenormal
coronalprofileinFig.2).Normalfissures(choroidal,Ch;fimbriodentate,
FD;andhippocampal, H)aremarkedfororientation.
B,Microscopiccoronalsectionofbodyofhippocampus showsclassiclossofcellsinCAlofhippocampuscompared withnormaldarktriangularpyramidalcells(arrows)
in CA2region.(HandE,xlOO)

tient and has been performed in an effort to
detect early onset of Alzheimer's disease and to
study normal age-associated memory impair
ment. MR spectroscopy may be of particular
importance in patients with a normal MR scan
and medically intractable epilepsy [7]. How
ever, the clinical usefulness of this technique in
studiesof the limbic systemhasbeenlimited by
many technical pitfalls. For example, in 1H MR
spectroscopy, in which the spectral peaks are
crowded under optimal conditions, magnetic
field inhomogeneities caused by the bone or air
interfaces(or both) near the hippocampuspro
ducebroadenedspectralpeaksand makequan
titative analysis difficult [7] (Fig. 7). However,
the useof small voxel sizes,obtainedwith spec
troscopicimaging techniquescoupledwith effi
cient magneticfield homogeneityoptimization,
may expand the clinical applications of MR
spectroscopyin the limbic system.
Refractory Epilepsy
Epilepsy affects 0.5—1%of the population in
the United States.Of theseindividuals, 15—30%
are refractory to medical treatment and are po
tential candidates for surgical resection [8].
Electroencephalographicstudies are the most
important localizing tools in these patients. If
imaging shows hippocampal sclerosis at the site
of a temporal lobe electroencephalographicab
normality, the surgical outcome is greatly im

1144 AJR:171,October1998
 ,@“ I .1
Downloaded from www.ajronline.org by 92.83.162.251 on 11/29/22 from IP address 92.83.162.251. Copyright ARRS. For personal use only; all rights reserved

,1 I

A B

Fig.9.—Hippocampal
sclerosis.
A,Coronalfastspin-echo12-weighted
scanshowsabnormal increasedsignalintensity
inbodyoflefthippocampus (arrow)compared withnormal rightside.
B,Coronalfastspin-echo12-weighted
scancaudalto A showsthatatrophyof hippocampus
onleftresultsin subtleincreasedsizeof leftchoroidalfissure(Ch)(arrow).
Normalthinner choroidal fissure on right side also is markedwith arrow for comparison.

Fig.10.—Fibrillary
astrocytoma.
A,Coronalfastspin-echo 12-weighted
scanshowsabnormal
focusofincreased
signalintensity
atjunction
ofrightamygdala
andhippocampal
head(arrow)(seeFig.4C,
left hippocampalsection).This finding should not be mistakenfor uncal recess of temporal horn (see Figs.4D and 4E).
B,Companion
11-weighted
imagesbefore(notshown)andaftergadolinium
administration
donotshowabnormality.

proved (i.e.. 8()—9O@7c

of these individuals
becomeseizure-free).This finding is significant
becauseone half of patientswith medically in
tractableseizureshavehippocampalsclerosis.
MR imaging is the technique of choice in
@¼@#@fT 7:
these patients because it has a 90% sensitivity
to hippocampal sclerosis,whereasCT is sensi
tive in only 2% of cases (Figs. 8 and 9). MR
imaging also is superior to CT in the detection
of other causesof refractory epilepsy, such as
congenital deformities, low-grade tumors (Fig.
tu
10), trauma, stroke, and infections. Recogni
tion that scalp electroencephalographsmay
falsely localize an abnormality to the hippo
campus is important. In this setting, imaging is
of utmost importance becauseit can prompt
Fig. 11.—Temporal
lobe ganglioglioma.Fastspin-echo 12-weighted image shows left inferior temporal lobe le
the use of depth electrodes to correctly localize sion(arrow)thatwasnotseenonunenhanced
11-weightedscans.Scalpelectroencephalograph
erroneously
the causative lesion (Fig. 1 1). indicated focus in oppositetemporal lobe. Subduralelectrodes correctly localized lesion.

AJR:171,October1998 1145

Summary
The hippocampus is a complex and fasci
nating region of the brain that has enormous
clinical significance. Specifically, small imag
ing abnormalities may cause major symp
toms. We believe that the detection of these
Downloaded from www.ajronline.org by 92.83.162.251 on 11/29/22 from IP address 92.83.162.251. Copyright ARRS. For personal use only; all rights reserved
lesions will be improved if imaging clinicians
have an organized reference that facilitates
identification of the cellular zones that com
prise the hippocampus.
Acknowledgments
We thank the Armed ForcesInstitute of Pa
thology, Washington, DC, for providing the
1146
Hayman et al.
true coronal brain slices. We are extremely 4. FullerGN,BurgerPC.Centralnervoussystem.In:
grateful for the expertise and patience provided Sternberg
SS,ed.Histologyfor pathologists,
2nd
ed.NewYork:Lippincon—Raven,
1997:243—282
for this undertakingby BrendaSchubert.
5. Tien RD. FelsbergGJ. Cram B. Normal anatomy
of the hippocampusand adjacenttemporallobe:
References high-resolution
fastspin—echo
MR imagesin vol
1. DuvernoyHM. The humanhippocampus: an at unteerscorrelatedwith cadaverichistologicsec
las of applied anatomy. Munich: Bergmann Ver tions. AiR 1992;l59: 1309—1313
lag,1988:1—45 6. Jack CR, Rydberg CH, Krecke KN, et al. Mesial
2. BronenRA, Cheung0. Relationshipof hippo temporalsclerosis:diagnosiswith fluid-attenu
campusandamygdala
tocoronalMRI landmarks. ated inversion-recoveryversusspin-echoMR im
Magn Reson Imaging 1991:9:449—457 aging. Radiology 1996;l99:367—373
3. Naidich TP, Daniels DL, Haughton VM, Williams 7. Tien RD. Neuroimaging clinics of North Amer
A, Pojunas K, PalaciosE. Hippocampalforma ica: the limbic system normal anatomy and pa
tion and related structures of the limbic lobe: ana thologv. Philadelphia: Saunders, 1997
tomic—MRcorrelation. 1. Surface features and 8. Jack CR. Magnetic resonance imaging in epi
coronal sections. Radiology 1987;l62:747—754 lepsy.MayoClinPmc 1996;7l:695—711
AJR:171,October1998