Microsurgical anatomy of the insula and the sylvian fissure

OBJECT: The purpose of this study was to define the topographic anatomy, arterial supply, and venous drainage of the insula and sylvian fissure. METHODS: The neural, arterial, and venous anatomy of the insula and sylvian fissure were examined in 43 cerebral hemispheres. CONCLUSIONS: The majority of gyri and sulci of the frontoparietal and temporal opercula had a constant relationship to the insular gyri and sulci and provided landmarks for approaching different parts of the insula. The most lateral lenticulostriate artery, an important landmark in insular surgery, arose 14.6 mm from the apex of the insula and penetrated the anterior perforated substance 15.3 mm medial to the limen insulae. The superior trunk of the middle cerebral artery (MCA) and its branches supplied the anterior, middle, and posterior short gyri; the anterior limiting sulcus; the short sulci; and the insular apex. The inferior trunk supplied the posterior long gyrus, inferior limiting sulcus, and limen area in most hemispheres. Both of these trunks frequently contributed to the supply of the central insular sulcus and the anterior long gyrus. The areas of insular supply of the superior and inferior trunks did not overlap. The most constant insular area of supply by the cortical MCA branches was from the prefrontal and precentral arteries that supplied the anterior and middle short gyri, respectively. The largest insular perforating arteries usually arose from the central and angular arteries and most commonly entered the posterior half of the central insular sulcus and posterior long gyrus. Insular veins drained predominantly to the deep middle cerebral vein, although frequent connections to the superficial venous system were found. Of all the insular veins, the precentral insular vein was the one that most commonly connected to the superficial sylvian vein.