Neurosurgical anatomy of the insula and Sylvian fissure in gliomas: literature data and own experience. The first report. Arteries




insular gliomas, lenticulostriate arteries, insular perforating arteries, surgical removal


Insular gliomas account for 25 % of all low-grade and 10 % of all high-grade gliomas. This complex neural and vascular anatomy of the insula and subinsular areas and the attendant risk of postoperative neurological deficit render resection of insular gliomas challenging. Postoperative morbidity can result from injury to these arteries. The cortex and adjacent subcortical structures of the insula are supplied with blood from the cortical insular perforating arteries and lenticulostriate arteries. The source of both types of arteries is the middle cerebral artery. To preserve these vessels, it is necessary to take into account their location while performing approach and tumor debulking.

The presurgical planning is extremely important for insular glioma surgery, which allows predicting the extent of removal and to assess the risk of postoperative morbidity. The digital subtractive angiography, CT angiography, MRI angiography make a full picture of the tumor relationship with the lenticulostriate arteries while it is almost impossible to identify the tumor involvement of the insular arteries.

The aim of insular glioma surgery is to achieve total removal while preserving critical arteries. This goal is complicated both by a small diameter of lenticulostriate and insular arteries, which intraoperatively complicates their identification and their involvement in tumor tissue. The intraoperative neuroimaging, neuronavigation, intraoperative neuromonitoring can help guide the extent of resection and prevent or minimize postoperative morbidity. However, these advanced technologies are often insufficient without a comprehensive understanding of the insular functional and vascular anatomy.

Author Biographies

Valentyn M. Kliuchka, Romodanov Neurosurgery Institute, Kyiv

Intracerebral Tumors Department

Volodymyr D. Rozumenko, Romodanov Neurosurgery Institute, Kyiv

Intracerebral Tumors Department

Tetyana A. Malysheva, Romodanov Neurosurgery Institute, Kyiv

Neuropathomorphology Department

Artem V. Rozumenko, Romodanov Neurosurgery Institute, Kyiv

Intracerebral Tumors Department

Andrii V. Dashchakovskyi, Romodanov Neurosurgery Institute, Kyiv

Intracerebral Tumors Department


1. Türe U, Yaşargil MG, Al-Mefty O, Yaşargil DC. Arteries of the insula. J Neurosurg. 2000 Apr;92(4):676-87. [CrossRef] [PubMed]

2. Delion M, Mercier P. Microanatomical study of the insular perforating arteries. Acta Neurochir (Wien). 2014 Oct;156(10):1991-7; discussion 1997-8. [CrossRef] [PubMed]

3. Tanriover N, Rhoton AL Jr, Kawashima M, Ulm AJ, Yasuda A. Microsurgical anatomy of the insula and the sylvian fissure. J Neurosurg. 2004 May;100(5):891-922. [CrossRef] [PubMed]

4. Türe U, Yaşargil DC, Al-Mefty O, Yaşargil MG. Topographic anatomy of the insular region. J Neurosurg. 1999 Apr;90(4):720-33. [CrossRef] [PubMed]

5. Eliava ShSh. [Microsurgical angioarchitectonics of depth structures of the brain and depth interarterial anastomoses]. Zh Vopr Neirokhir Im N N Burdenko. 2005 Oct-Dec;(4):3-7; discussion 8. Russian. [PubMed]

6. Bykanov AE, Pitskhelauri DI, Pronin IN, Tonoyan AS, Kornienko VN, Zakharova NE, Turkin AM, Sanikidze AZ, Shkarubo MA, Shkatova AM, Shults EI. 3D-TOF MR-angiography with high spatial resolution for surgical planning in insular lobe gliomas. Zh Vopr Neirokhir Im N N Burdenko. 2015;79(3):5-14. English, Russian. [CrossRef] [PubMed]

7. Jakola AS, Berntsen EM, Christensen P, Gulati S, Unsgård G, Kvistad KA, Solheim O. Surgically acquired deficits and diffusion weighted MRI changes after glioma resection--a matched case-control study with blinded neuroradiological assessment. PLoS One. 2014 Jul 3;9(7):e101805. [CrossRef] [PubMed] [PubMed Central]

8. Saito R, Kumabe T, Inoue T, Takada S, Yamashita Y, Kanamori M, Sonoda Y, Tominaga T. Magnetic resonance imaging for preoperative identification of the lenticulostriate arteries in insular glioma surgery. Technical note. J Neurosurg. 2009 Aug;111(2):278-81. [CrossRef] [PubMed]

9. Moshel YA, Marcus JD, Parker EC, Kelly PJ. Resection of insular gliomas: the importance of lenticulostriate artery position. J Neurosurg. 2008 Nov;109(5):825-34. [CrossRef] [PubMed]

10. Lang FF, Olansen NE, DeMonte F, Gokaslan ZL, Holland EC, Kalhorn C, Sawaya R. Surgical resection of intrinsic insular tumors: complication avoidance. J Neurosurg. 2001 Oct;95(4):638-50. [CrossRef] [PubMed]

11. Šteňo A, Jezberová M, Hollý V, Timárová G, Šteňo J. Visualization of lenticulostriate arteries during insular low-grade glioma surgeries by navigat ed 3D ultrasound power Doppler: technical note. J Neurosurg. 2016 Oct;125(4):1016-1023. [CrossRef] [PubMed]

12. Duffau H, Capelle L, Lopes M, Faillot T, Sichez JP, Fohanno D. The insular lobe: physiopathological and surgical considerations. Neurosurgery. 2000 Oct;47(4):801-10; discussion 810-1. [CrossRef] [PubMed]

13. Duffau H. A personal consecutive series of surgically treated 51 cases of insular WHO Grade II glioma: advances and limitations. J Neurosurg. 2009 Apr;110(4):696-708. [CrossRef] Erratum in: J Neurosurg. 2011 May;114(5):1486. [PubMed]

14. Duffau H, Taillandier L, Gatignol P, Capelle L. The insular lobe and brain plasticity: Lessons from tumor surgery. Clin Neurol Neurosurg. 2006 Sep;108(6):543-8. [CrossRef] [PubMed]

15. Rao AS, Thakar S, Sai Kiran NA, Aryan S, Mohan D, Hegde AS. Analogous Three-Dimensional Constructive Interference in Steady State Sequences Enhance the Utility of Three-Dimensional Time of Flight Magnetic Resonance Angiography in Delineating Lenticulostriate Arteries in Insular Gliomas: Evidence from a Prospective Clinicoradiologic Analysis of 48 Patients. World Neurosurg. 2018 Jan;109:e426-e433. [CrossRef] [PubMed]

16. Yaşargil MG, Reeves JD. Tumours of the limbic and paralimbic system. Acta Neurochir (Wien). 1992;116(2-4):147-9. [CrossRef] [PubMed]

17. Kumabe T, Nakasato N, Suzuki K, Sato K, Sonoda Y, Kawagishi J, Yoshimoto T. Two-staged resection of a left frontal astrocytoma involving the operculum and insula using intraoperative neurophysiological monitoring--case report. Neurol Med Chir (Tokyo). 1998 Aug;38(8):503-7. [CrossRef] [PubMed]

18. Hervey-Jumper SL, Berger MS. Insular glioma surgery: an evolution of thought and practice. J Neurosurg. 2019 Jan 1;130(1):9-16. [CrossRef] [PubMed]

19. Ribas EC, Yagmurlu K, Wen HT, Rhoton AL Jr. Microsurgical anatomy of the inferior limiting insular sulcus and the temporal stem. J Neurosurg. 2015 Jun;122(6):1263-73. [CrossRef] [PubMed]

20. Vanaclocha V, Sáiz-Sapena N, García-Casasola C. Surgical treatment of insular gliomas. Acta Neurochir (Wien). 1997;139(12):1126-34; discussion 1134-5. [CrossRef] [PubMed]

21. Neuloh G, Pechstein U, Schramm J. Motor tract monitoring during insular glioma surgery. J Neurosurg. 2007 Apr;106(4):582-92. [CrossRef] [PubMed]

22. Hentschel SJ, Lang FF. Surgical resection of intrinsic insular tumors. Neurosurgery. 2005 Jul;57(1 Suppl):176-83; discussion 176-83. [CrossRef] [PubMed]

23. Yasargil MG, Krisht AF, Türe U, Al-Mefty O, Yasargil DC. Microsurgery of Insular Gliomas: Part I—Surgical Anatomy of the Sylvian Cistern. Contemporary Neurosurgery. 2017 Jul 30;39(11):1-8. [CrossRef]

24. Marinkovic S, Gibo H, Milisavljevic M, Cetkovic M. Anatomic and clinical correlations of the lenticulostriate arteries. Clin Anat. 2001 May;14(3):190-5. [CrossRef] [PubMed]

25. Rey-Dios R, Cohen-Gadol AA. Technical nuances for surgery of insular gliomas: lessons learned. Neurosurg Focus. 2013 Feb;34(2):E6. [CrossRef] [PubMed]

26. Kawaguchi T, Kumabe T, Saito R, Kanamori M, Iwasaki M, Yamashita Y, Sonoda Y, Tominaga T. Practical surgical indicators to identify candidates for radical resection of insulo-opercular gliomas. J Neurosurg. 2014 Nov;121(5):1124-32. [CrossRef] [PubMed]

27. Hervey-Jumper SL, Li J, Lau D, Molinaro AM, Perry DW, Meng L, Berger MS. Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period. J Neurosurg. 2015 Aug;123(2):325-39. [CrossRef] [PubMed]



How to Cite

Kliuchka, V. M., Rozumenko, V. D., Malysheva, T. A., Rozumenko, A. V., & Dashchakovskyi, A. V. (2020). Neurosurgical anatomy of the insula and Sylvian fissure in gliomas: literature data and own experience. The first report. Arteries. Ukrainian Neurosurgical Journal, 26(3), 13–21.



Review articles