圖1。左顳葉的上位圖。1、楔片;2、顳後橫回;3、海馬旁回;4、顳橫回中部;5、顳橫回;6、海馬頭;7,平麵polare;8、鉤骨前內側麵; 9, superior temporal gyrus, where the anterior portion of the temporal lobe starts to deviate medially. (Images courtesy of AL Rhoton, Jr.)

圖2。A，左腦半球側位圖。1、額下回三角部;2、中央前回;3、中央後回;4, supramarginal回;5, pars orbitalis;6, pars opercularis;7、顳上回與顳橫回交界處;8、外耳道。 Asterisk, at this point, the planum polare starts to deviate medially. Note the large space in the sylvian fissure between the structures 1, 5, and 6. B, sagittal magnetic resonance imaging (MRI) scan at the surface of the left hemisphere. 1, postcentral gyrus. Asterisk, projection of the external acoustic meatus over the petrous temporal bone. Heschl’s gyrus (arrow). C, sagittal MRI scan at the opercular level of the left hemisphere. 1, postcentral gyrus. Asterisk, projection of the external acoustic meatus over the petrous temporal bone. Heschl’s gyrus (arrow). D, anterobasal view of the cerebrum. 1, pars triangularis; 2, pars orbitalis; 3, pars opercularis; 4, precentral gyrus. The large arrow indicates where the medial deviation of the planum polare begins. The small arrow indicates where the medial deviation of the planum polare intensifies. E, superior view of the left hemisphere. An axial cut has been made to expose the lateral ventricle. The frontal and parietal opercula have been removed to expose the insula and the temporal opercula. 1, rostrum of the corpus callosum; 2, head of the caudate nucleus; 3, planum polare; 4, insula; 5, thalamus; 6, Heschl’s gyrus; 7, choroid plexus of the atrium of the lateral ventricle covering the pulvinar of the thalamus; 8, middle transverse temporal gyrus; 9, posterior transverse temporal gyrus. The arrow indicates the medial end of the Heschl’s gyrus that points toward the posterior limb of the internal capsule and toward the atrium of the lateral ventricle. The arrowheads indicate the location of the angiographic sylvian point. (Images courtesy of AL Rhoton, Jr.)

圖3。右半球基本視圖。顳骨蓋被切除，露出額蓋和頂骨蓋。1、外側眶回;2、眶前回;3、內側眶回;4、眶後回;5,腹直肌回;6, pars triangularis;7, pars opercularis;8、中央前回; 9, postcentral gyrus; 10, supramarginal gyrus. Asterisk, pars orbitalis. (Images courtesy of AL Rhoton, Jr.)

圖4。A，左半球的上外側視圖。1、中央前回;2、中央後回;3, supramarginal回;4、額下溝;5、額下回蓋部;6、顳上回;額下回三角部。箭頭表示外側裂後支的上行和下行末端分支。 The arrowhead indicates posterior ramus of the sylvian fissure. The largest transverse diameter of the cerebrum usually corresponds to the level of postcentral gyrus and to the middle and the superior temporal gyri (at the level of the postcentral gyrus). B, superolateral view of the same specimen shown in A. A transverse cut has been made by following a line drawn from the base of the pars triangularis of the inferior frontal gyrus to the supramarginal gyrus, immediately above the posterior ramus of the sylvian fissure. 1, frontal horn; 2, head of the caudate nucleus; 3, atrium; 4, pars triangularis; 5, pars opercularis; 6, precentral gyrus; 7, postcentral gyrus; 8, supramarginal gyrus; 9, superior temporal gyrus. C, the operculum of the supramarginal gyrus has been removed to display the middle and posterior transverse temporal gyri and the medial end of the Heschl’s gyrus. 1, medial part of the Heschl’s gyrus (anterior transverse temporal gyrus); 2, middle transverse temporal gyrus; 3, posterior transverse temporal gyrus; 4, precentral gyrus; 5, postcentral gyrus; 6, posterior end of the superior temporal gyrus turning around the descending branch of the posterior ramus of the sylvian fissure to become the supramarginal gyrus; 7, superior temporal gyrus. The supramarginal gyrus constitutes the posterior wall of the posterior ramus of the sylvian fissure. D, the operculum of the postcentral gyrus has been removed to display the Heschl’s gyrus and posterior end of the insula. 1, posterior long gyrus of the insula; 2, Heschl’s gyrus; 3, middle transverse temporal gyrus; 4, posterior transverse temporal gyrus; 5, pars opercularis; 6, precentral gyrus; 7, supramarginal gyrus; 8, superior temporal gyrus. E, the operculum of the precentral gyrus has been removed to display the posterior part of the planum polare, located immediately anterior to the Heschl’s gyrus, and also to display the posterior half of the insula. 1, posterior insula; 2, pars triangularis; 3, pars opercularis; 4, Heschl’s gyrus; 5, middle transverse temporal gyrus; 6, posterior transverse temporal gyrus; 7, planum polare; 8, superior temporal gyrus. F, the pars opercularis of the inferior frontal gyrus has been removed to display the anterior portion of the planum polare and the anterior portion of the insula. 1, insula; 2, pars triangularis; 3, Heschl’s gyrus; 4, planum polare. G, frontal view of the cerebrum. The largest transverse diameter of the brain in the suprasylvian region corresponds to the postcentral gyrus (large arrows). The largest transverse diameter of the brain in the infrasylvian region corresponds to the superior or middle temporal gyrus, in the coronal plane of the postcentral gyrus (small arrows). (Images courtesy of AL Rhoton, Jr.)

圖5。A，大腦的前顱底觀。箭頭表示額顳蛛網膜反射連接額葉眶麵至極平麵。1、眶前回;2、外側眶回;3、腹直肌回;4、眶後回;5、內側眶回。B，術中照片顯示翼點開顱和硬腦膜開窗後右半球基底麵。圖中額顳蛛網膜(箭頭)在雙極鉗尖端和吸引管之間被拉伸。 The frontotemporal arachnoid membrane is continuous with the carotid, chiasmatic, and olfactory cisterns. In this figure, the olfactory tract is shown at the right side of the tip of the suction tube, and the optic nerve is shown at the right side of the olfactory tract. C, sagittal MRI scan. The arrows indicate the intermediate plane of the sylvian fissure on the basal surface, located between the posterior portion of the orbital gyri and the planum polare. The arrowheads indicate the anterior operculoinsular compartment of the sylvian fissure. D, superolateral view of the left hemisphere. A spatula has been placed in the horizontal ramus of the sylvian fissure that continues medially with the anterior limiting sulcus of the insula. The precentral gyrus is usually related to the mid-posterior portion of the insula. 1, precentral gyrus; 2, frontal horn; 3, anterior limiting sulcus of the insula; 4, junction between the inferior and the superior limiting sulci of the insula; 5, anterior portion of the insula; 6, pars orbitalis; 7, Heschl’s gyrus. (Images courtesy of AL Rhoton, Jr.)

圖6(模擬)。A，右側島葉側位圖。在本標本中，分隔前短回和中短回的島葉短溝穿過島葉尖並延伸至島葉limen。1、前短回;2、中短回;3、後短回;4、前長回;5、後長回。島葉中央溝位於島葉後短回和前長回之間。虛線表示島葉下界溝。 B, basal view of the right insula to display the inferolateral facet. In this specimen, the short insular sulcus that runs between the anterior and middle short gyri also traverses the insular apex and extends to the limen insulae. 0, accessory gyrus; 1’, transverse gyrus of Eberstaller; 1, anterior short gyrus; 2, middle short gyrus; 3, posterior short gyrus; 2 + 3, fusion of the middle and posterior short gyri; 4, anterior long gyrus; 5, posterior long gyrus; IP, insular pole; RI, rhinal incisura; APS, anterior perforated substance; TS, temporal stem; OT, optic tract; AM, amygdala; CP, insertion of the choroid plexus at the inferior choroidal point. Double asterisk, short insular sulcus. The dotted line indicates the inferior limiting sulcus of the insula. Asterisk, medial nucleus of amygdala. The medial nucleus of the amygdala is located anterior and slightly superior to the inferior choroidal point, and it is in close proximity to the optic tract and the upper part of the crus cerebri. The posteromedial orbital lobule is composed of the medial portion of the posterior orbital gyrus and by the posterior portion of the medial orbital gyrus. C, frontal view of the right insula. 0, accessory gyrus; 1’, transverse gyrus of Eberstaller; 1, anterior short gyrus; 2, middle short gyrus; Caudate N, head of the caudate nucleus. The dotted line indicates the anterior limiting sulcus of the insula. The insular edge and the superolateral and inferolateral facets of the insula are more evident at the anterior portion of the insula as shown in this figure. D, laterobasal view of the cerebrum. The posterior orbital gyrus has been removed to display the overall view of the anterior surface and the inferolateral facet of the insula. 0, accessory gyrus; 1’, transverse gyrus of Eberstaller; 1, anterior short gyrus; 2, middle short gyrus and the insular apex; 3, posterior short gyrus; 4, insular pole; 5, anterior long gyrus; 6, posterior long gyrus; 7, horizontal ramus of the sylvian fissure; 8, pars triangularis. Asterisk, posteromedial orbital lobule. The anterior zone of the insula (anterior surface and the short gyri) forms a pyramidal structure with its apex pointing laterally and inferiorly. The insular pole and the limen insulae are located more medially and posteriorly in relation to pars triangularis. 1, frontal horn; 2, accessory gyrus of the insula; 3, lentiform nucleus and the internal capsule; 4, head of the caudate nucleus; 5, genu of the MCA; 6, insular pole; 7, anterior perforated substance; 8, amygdala; 9, head of the hippocampus. (Images courtesy of AL Rhoton, Jr.)

圖6 (E-J)。E,正麵觀點。在視神經水平的島葉前部做了冠狀切口。在島葉前部，上外側小麵和下外側小麵以及島葉邊緣更為明顯。在右半球，冠狀切麵包括小麵下外側前短回的延伸、Eberstaller橫回及其與眶後內側小葉的交界處(藍色箭頭)。在左半球，冠狀切麵更前麵，包括後眶回。在這一水平，尾狀核的頭部位於嗅溝上方的灰質上，並被一層薄薄的白質與嗅溝隔開。慢形核位於眶後內側小葉上方和Eberstaller橫回上方，並被一層由隱窩插入的白質與橫回隔開。1、尾狀核頭部;2、上緣溝; 3, foramen of Monro (left); 4, lentiform nucleus and olfactory sulcus; 5, rectus gyrus; 6, optic nerve and olfactory tract; 7, posterior orbital gyrus; 8, posteromedial orbital lobule. The arrowheads indicate superior insular cleft and superolateral facet of insula. The white arrow indicates transverse gyrus of Eberstaller. The blue arrow indicates junction between the transverse gyrus and the posteromedial orbital lobule. IE, insular edge. Asterisk, paraolfactory gyrus. The red arrowhead indicates claustrum. The head and body of the caudate nucleus are located more superiorly than the superior limiting sulcus of the insula. G, coronal MRI scan of the posterior portion of the insula. H, coronal MRI scan of the middle portion of the insula. F, laterobasal view of the right insula. 0, accessory gyrus; 1’, transverse gyrus of Eberstaller; 1, anterior short gyrus; 2, middle short gyrus; 3, posterior short gyrus; 2 + 3, junction between the middle and the posterior short gyri; 4, anterior long gyrus; 5, posterior long gyrus; IA, insular apex; IP, insular pole; CS, central sulcus of insula. The dotted line indicates the location of the inferior limiting sulcus of insula. I, schematic drawing of the anterolateral aspect of the right insula. 0, accessory gyrus; 1’, transverse gyrus of Eberstaller; 1, anterior short gyrus; 2, middle short gyrus; 3, posterior short gyrus; 4, anterior long gyrus; 5, posterior long gyrus; IA, insular apex. J, schematic drawing depicting a posterosuperomedial view of the walls of the insula. ANT., anterior; SUP., superior; INS., insular; INF., inferior. 1, frontal horn; 2, accessory gyrus of the insula; 3, lentiform nucleus and the internal capsule; 4, head of the caudate nucleus; 5, genu of the MCA; 6, insular pole; 7, anterior perforated substance; 8, amygdala; 9, head of the hippocampus. (Images courtesy of AL Rhoton, Jr.)

圖6 (K-L)。K，腦島壁後上視圖示意圖。前壁為黃色，上外側小關節麵為淺藍色，下外側小關節麵為紅色。L，右額葉基本視圖。1、眶前回;2、外側眶回;3、內側眶回;4、眶後回;5,腹直肌回;6, pars orbitalis; 7, transverse gyrus; 8, insular pole. The arrows indicate anterior insular cleft. The arrowheads indicate posteromedial limb of the orbital sulcus. Asterisk, posteromedial orbital lobule, just anterior to the lateral olfactory stria and lateral to the olfactory sulcus. 1, frontal horn; 2, accessory gyrus of the insula; 3, lentiform nucleus and the internal capsule; 4, head of the caudate nucleus; 5, genu of the MCA; 6, insular pole; 7, anterior perforated substance; 8, amygdala; 9, head of the hippocampus. (Images courtesy of AL Rhoton, Jr.)

圖6 (mn)。米,正麵觀點。在頸內動脈分叉處做冠狀切口(前穿孔物質)。1、腦島;2、內囊;3、丘腦;4、隱窩、外囊和極囊;5,豆狀核;6、丘腦紋靜脈、穹窿柱和前聯合;7,下丘腦; 8, lateral lenticulostriate arteries and insular pole; 9, lamina terminalis and anterior cerebral artery (A1 segment); 10, middle cerebral artery (MCA) (M2 segment); 11, internal carotid artery (supraclinoid segment); 12, olfactory tract and optic nerve. The arrowheads indicate the extent of the M1 segment of the MCA from the carotid bifurcation to the limen insulae. N, basal view of the right hemisphere. A coronal section, followed by an axial section, has been performed at the level of the anterior perforated substance. 1, frontal horn; 2, accessory gyrus of the insula; 3, lentiform nucleus and the internal capsule; 4, head of the caudate nucleus; 5, genu of the MCA; 6, insular pole; 7, anterior perforated substance; 8, amygdala; 9, head of the hippocampus. (Images courtesy of AL Rhoton, Jr.)

圖7。A，右半球額基麵圖。極平麵的前部向下縮以顯示島極的前部。1、眶前回;2、內側眶回;3、腹直肌回;4, pars triangularis;5、眶後回;6, pars opercularis;7、島葉前部短回; 8, anterior perforated substance. The arrowheads indicate the limen insulae. B, lateral view of the left cerebral hemisphere. The inferior frontal and supramarginal gyri have been removed to display the relationship between the insula and the opercula of the precentral and postcentral gyri. 1, precentral gyrus; 2, central sulcus; 3, postcentral gyrus; 4, anterior short gyrus of the insula; 5, posterior orbital gyrus and the anterior insular cleft; 6, central sulcus and the anterior long gyrus of the insula; 7, posterior long gyrus of the insula and the inferior limiting sulcus of the insula; 8, insular apex and insular pole; 9, middle temporal gyrus. C, lateral view of the left cerebral hemisphere. The posterior portion of the superior temporal gyrus, the upper portion of the middle temporal gyrus, and the supramarginal gyrus have been removed. 1, precentral gyrus; 2, corpus callosum; 3, postcentral gyrus; 4, septum pellucidum at the level of the frontal horn; 5, upper portion of the atrium; 6, superior temporal gyrus; 7, calcar avis and the glomus of the atrium (choroid plexus); 8, hippocampus; 9, inferior temporal gyrus. D, superolateral view of the right cerebral hemisphere. 1, left atrium; 2, left frontal horn; 3, splenium of the corpus callosum; 4, foramen of Monro and caudate nucleus; 5, bulb of the callosum; 6, thalamus; 7, anterior extremity of the anterior limb of internal capsule; 8, calcar avis; 9, lentiform nucleus; 10, anterior insular cleft; 11, collateral trigone; 12, sublenticular portion of the internal capsule. (Images courtesy of AL Rhoton, Jr.)

圖8。A，蝶平麵處的冠狀切麵，就在尾狀核頭部的前方。1、尾狀核頭部;2、膝胼胝體;3、胼胝體前庭;4、扣帶回下延;5、內側額回下延;6、外側眶回;7、眶後回;8、內側眶回; 9, rectus gyrus and the olfactory tract. The superior rostral sulcus is located between the 4 and 5, and the inferior rostral sulcus is located between the 5 and 9. The posteromedial limb of the orbital sulcus is located between the 7 and 8. The olfactory sulcus is located superiorly to the olfactory tract. B, a coronal cut was performed at a level between the cuts shown in Figs. 8A and 6C. 1, transverse gyrus of Eberstaller; 2, posteromedial orbital lobule. C, coronal cut performed at the level of the optic chiasm (at the anterior perforated substance). 1, caudate nucleus; 2, thalamus, choroidal fissure, and thalamostriate vein; 3, internal capsule, transition between the anterior limb and the genu; 4, foramen of Monro and column of fornix; 5, putamen; 6, globus pallidus; 7, lamina terminalis and hypothalamus; 8, optic chiasm. Asterisk, anterior commissure. (Images courtesy of AL Rhoton, Jr.)

圖9。A，大腦的基本視圖。1、眶前回;2、嗅徑;3、外側眶回;4、內側眶回;5,腹直肌回;6,腦島;7、前部物質穿孔;8日島極; 9, amygdala; 10, carotid bifurcation, oculomotor nerve, and the optic tract; 11, head of the hippocampus. The arrowheads indicate the extent of M1 segment. B, superior view. 1, orbit; 2, genu of the MCA; 3, planum polare; 4, olfactory tract and optic nerve; 5, anterior cerebral artery; 6, insular pole; 7, anteromedial surface of the uncus; 8, posterior communicating artery; 9, head of the hippocampus; 10, posteromedial surface of the uncus, anterior choroidal artery, and P2A segment of the posterior cerebral artery; 11, medial end of the Heschl’s gyrus and the sylvian point; 12, midbrain; 13, atrium. M1, M2, M3, M4, segments of the MCA. C, lateral view of the left insula and M2 segment of the MCA. 1, corpus callosum; 2, superior limiting sulcus of insula; 3, anterior limiting sulcus of insula; 4, inferior limiting sulcus of the insula; 5, straight sinus; 6, orbit; 7, tentorial edge and middle fossa. D, anteroposterior (AP) view as in angiography. 1, parieto-occipital artery; 2, lingual gyrus and calcarine artery; 3, calcar avis, atrium, and posterior transverse temporal gyrus; 4, vein of Galen; 5, glomus of atrium and sylvian point; 6, middle transverse temporal gyrus; 7, tentorial edge and trochlear nerve; 8, P2P segment of the posterior cerebral artery, parahippocampal gyrus, and fornix; 9, superior limiting sulcus of the insula; 10, inferior choroidal point (entry point of the anterior choroidal artery in the temporal horn); 11, Heschl’s gyrus; 12, lentiform nucleus; 13, crus cerebri; 14, apex and the posteromedial surface of the uncus and the anterior choroidal artery; 15, P1 segment of the posterior cerebral artery and the posterior communicating artery; 16, head of the hippocampus; 17, supraclinoid carotid artery and anteromedial surface of the uncus; 18, limen insulae and insular pole; 19, planum polare; 20, deep middle cerebral vein; 21, anterior cerebral artery and optic nerve; 22, lesser wing of the sphenoid; 23, genu of the MCA; M1, sphenoid segment of the MCA; M2, insular segment of the MCA; M3, opercular segment of the MCA; M4, cortical segment of the MCA; IE, insular edge. (Images courtesy of AL Rhoton, Jr.)

圖10。A，頸動脈造影，正位視圖。紅色小箭頭表示MCA的M2段。綠色箭頭表示平麵極上的MCA的M3段。綠色箭頭表示MCA在顳平麵上的M3段。藍色箭頭表示頂部區域MCA的M4段。藍色箭頭表示頂內溝的位置。紫色箭頭表示島葉上緣溝。紅色的大箭頭表示三角肌部尖端的位置投影，就在中樞肌膝的遠端。B，右腦半球內側切麵，去除小腿大腦以顯示M1段在這個投影中的軌跡。 1, thalamus; 2, M1 segment of the MCA; 3, uncus and the inferior choroidal point; 4, anterior cerebral artery; 5, anterior choroidal artery; 6, P2A segment of posterior cerebral artery; 7, posterior communicating artery; 8, P1 segment of posterior cerebral artery; 9, supraclinoid carotid artery. C, carotid angiography, lateral view. The red arrows indicate anterior limiting sulcus. Blue arrows indicate superior limiting sulcus. The green arrows indicate inferior limiting sulcus. M, sylvian point. (Images courtesy of AL Rhoton, Jr.)

圖11。A，術中照片顯示標準右側翼點開顱術後的大腦暴露。吸管的尖端向內側收縮了三角肌部。1、眶後回;2、眶側回(眶部)。藍色箭頭表示基麵額顳蛛網膜反射。黑色箭頭表示側表麵的額顳蛛網膜反射。B, a的延續。額顳蛛網膜被分開，顯示基底麵上的外側裂的前眼室。1、蝶翼的小翼;2、平麵polare; 3, insular apex. The posterior orbital gyrus is retracted medially by the tip of the suction tube. The black arrowheads indicate the frontotemporal arachnoid membrane. The blue arrow indicates the beginning of the anterior insular cleft. C, continuation of B. The frontotemporal arachnoid membrane and the anterior opercular compartment have been further split to display the anterior insular compartment. The M1 segment of the MCA courses in the lower part of the anterior operculoinsular compartment (sphenoidal compartment). The blue arrow indicates the anterior insular cleft. (Images courtesy of AL Rhoton, Jr.)

圖12。A，左半球側麵圖。眶部已經向前方和上方收縮。1、中央前回;2、中央後回;3、三角部、水平前支和外側裂前升支;4, orbitalis;5, pars opercularis;6、眶後回和前島葉裂;7、蝶骨的小翼。 Asterisk, insular apex. M2, insular segment of the MCA that has just turned around the insular pole (just distal to the genu of the MCA). B, same specimen in A in surgical position (left pterional exposure). The spatula on the left side is retracting the planum temporale, and the spatula on the right side is retracting the posterior portion of the pars orbitalis. 1, lesser wing of sphenoid; 2, superior temporal gyrus; 3, pars orbitalis; 4, middle temporal gyrus; 5, posterior orbital gyrus; 6, anterior insular cleft and anterior short gyrus of the insula; 7, posterior long gyrus and the inferior limiting sulcus of the insula; 8, pars triangularis; 9, precentral gyrus; 10, pars opercularis; 11, Heschl’s gyrus; 12, postcentral gyrus; M2, insular segment of the MCA that has just turned around the insular pole (just distal to the genu of the MCA). Asterisk, insular apex. The arrowheads indicate the sharp transition between the basal and lateral surfaces of the cerebrum. C, AP view of a right carotid angiography. Note the laterally deviated supraclinoid carotid artery, the initial upward course followed by a downward curve of the M1, and then a rather horizontal course to turn around the insular pole. D, the expected intraoperative course of the M1 shown in C. (Images courtesy of AL Rhoton, Jr.)

圖13。A，左頸動脈造影的正位圖，顯示MCA動脈瘤指向下方。B，同一血管造影術的側位片顯示A中動脈動脈瘤指向前方和下方。C，手術暴露後，左翼點開顱後，硬腦膜打開。1、pars orbitalis;2、顳上回;3, pars triangularis。D,術中照片。將外側裂裂至眶部近端以顯露動脈瘤。1、外側淺脈; 2, supraclinoid carotid artery; 3, optic nerve and anterior cerebral artery; 4, M1 proximal to the aneurysm; 5, MCA distal to the aneurysm; 6, pars orbitalis; 7, pars triangularis. The olfactory tract is located beneath the tip of the bipolar forceps. E, the aneurysm shown in D was clipped and the dome opened and cut (at the tip of the suction tube). 1, temporal branch of the MCA and the planum polare; 2, carotid artery; 3, pars orbitalis. F, overall view of the surgical exposure after aneurysm clipping. Note the location of the clip (which indicates the location of the aneurysm) and the location of the pars triangularis (which indicates approximately the location of the insular apex, just distal to the insular pole and to the genu of the MCA). 1, pars orbitalis; 2, pars triangularis. (Images courtesy of AL Rhoton, Jr.)

圖14。A，左頸動脈造影的AP視圖，顯示MCA動脈瘤起源於MCA的膝部近端，在M1的遠端，在這個投影上指向上方。B, a中相同的頸動脈造影的側位投影。由於血管的疊加，動脈瘤很難顯示。C，血管造影- ct顯示動脈瘤(箭頭)。D，左側翼點開顱和硬腦膜開口處的手術暴露。星號,pars triangularis。E，外側裂在近端三角肌(箭頭)處裂開。注意動脈瘤與三角肌末端之間的距離(箭頭所示)。頸動脈分叉位於抹刀尖的水平。1、頸動脈鞘上。(圖片由AL Rhoton Jr.提供)

圖15。A，左頸動脈造影的正位圖，顯示大約在頸動脈分叉和中動脈膝之間的中動脈動脈瘤。B，血管造影-計算機斷層掃描(CT)三維重建顯示同一動脈瘤。C，血管造影- ct掃描三維重建，側位圖。D，左側翼點開顱和硬腦膜打開後暴露。星號,pars triangularis。E，外側裂在近三角肌(星號)處裂開。箭頭表示頸動脈分叉。箭頭表示動脈瘤的位置。注意三角部之間的距離和動脈瘤的位置。 F, the aneurysm was clipped, and the frontal branch of the MCA bifurcation was identified. (Images courtesy of AL Rhoton, Jr.)

圖16。A，軸向CT掃描。左外側裂有血腫。B，血管造影- ct冠狀麵。遠端MCA動脈瘤(箭頭);它位於中側頸椎骨膝和外側點中間的略遠端。C，血管造影- ct，側位。箭頭表示動脈瘤，箭頭表示腦尖。動脈瘤位於島葉中三分之一到後三分之一之間的過渡水平，靠近下界限溝。D，術中照片描述了左翼點開顱和硬腦膜打開後的大腦表麵。 The intense subpial hemorrhage makes the identification of the sulci and gyri difficult. The authors’ interpretation of the case was 1) pars triangularis, 2) pars opercularis, 3) precentral gyrus, 4) postcentral gyrus. Temp., temporal. E, intraoperative photograph showing the aneurysm arising from a bifurcation of an M2 branch. The arrows indicate the neck of the aneurysm. The arrowheads indicate the distal branches of the M2 branch. F, intraoperative photograph. The aneurysm was clipped using only the tip of the clip (Because of a lack of variety of clips available at the time of the surgery), and the clot in the sylvian fissure was removed. The arrowhead indicates the location of the neck of the aneurysm. (Images courtesy of AL Rhoton, Jr.)

圖17。A，右半球矢狀位MRI掃描，顯示島葉腫瘤和額葉蛛網膜囊腫。B，軸向MRI掃描。腫瘤占據腦島後三分之二，保留前2短回(前短回和中短回)，也保留後長回。腫瘤被扁形核限製在內側。C，冠狀核磁共振掃描。腫瘤的上邊界位於外側骨裂的外側腔室的同一水平。D，右側翼點開顱後的手術暴露，隨後是硬腦膜打開和外側裂劈開。M2, MCA島葉段;,腦島。 Note that the tumor has encased the MCA. E, final aspect of the brain after tumor removal. The branches of the MCA were preserved. The whitish color of the arteries was owing to frequent application of the papaverine to prevent vasospasm. F, postoperative coronal MRI scan performed 8 months after surgery. G, postoperative axial MRI scan performed 8 months after surgery. The arrow indicates the frontal resection. (Images courtesy of AL Rhoton, Jr.)

圖18。A，軸向MRI掃描。B，島葉前部MRI冠狀位掃描。注意右側的上外側島葉裂缺失。箭頭指示皮質發育不良．C，右側翼點開顱手術後暴露，硬腦膜打開和外側裂裂。M2, MCA島葉段;,腦島。星號,皮質發育不良。D，去除皮質發育不良後的術中照片。E，術後冠狀位MRI掃描顯示皮質發育不良切除。F，術後軸向MRI掃描。(圖片由AL Rhoton Jr.提供)

圖19所示。A，矢狀位MRI掃描顯示位於島葉長回的海綿狀瘤，大約在上下界溝的中間。B，軸向MRI掃描。C，冠狀核磁共振掃描。D，右側翼點外側入路術後術中照片。箭頭指示位於島葉唯一長回的海綿狀瘤。箭頭表示阻止顳葉進一步側縮的Heschl回。E，海綿狀瘤切除後的術中照片。F，術後1天CT掃描。注意切除腔接近內囊後肢。 G, postoperative MRI performed 3 months after the surgery showed total resection of the cavernoma. (Images courtesy of AL Rhoton, Jr.)

圖20。A，矢狀核磁共振掃描。腫瘤位於右島葉後部。之前的手術顯然到達了島葉前部(箭頭)。B，軸向MRI掃描。腫瘤位於腦島後部。腫瘤的後內側界限與內囊後肢密切相關;此時沒有介入的慢狀核。C，冠狀核磁共振掃描。之前的手術切除了顳和額蓋，也切除了島葉前部。 Note that the insula edge is still prominent at this cut on the left side, indicating that this is the anterior insula. D, intraoperative photograph after opening the posterior ramus of the sylvian fissure. The tumor (whitish tissue) occupies the posterior zone of the insula. E, intraoperative photograph after the tumor removal. F, postoperative axial MRI scan depicting the resection of the tumor. (Images courtesy of AL Rhoton, Jr.)

圖21。A，軸向MRI掃描顯示左側額葉腫瘤。B，冠狀核磁共振掃描。C，矢狀MRI掃描顯示額基底區出現腫瘤。D，矢狀核磁共振掃描。箭頭表示前島葉裂。腫瘤局限於額眶區。E，左翼點開顱後的術中照片。這些字母表示左額葉有癲癇樣的刺突。F，術中照片顯示前島葉裂打開。 The anterior surface of the insula was covered by the cottonoid. G, postoperative axial MRI scan. H, postoperative coronal MRI scan. I, postoperative sagittal MRI scan. The mediotemporal structures also were removed. (Images courtesy of AL Rhoton, Jr.)

圖22。A，軸向MRI掃描。眶後內側小葉信號增高。B，冠狀核磁共振掃描。有一薄層白質將可疑區域(對應眶內側後小葉)與尾狀核的下部分隔開。C，右側翼點開顱後第二次手術的術中照片。1、嗅徑;2、可疑組織;3、視交叉與頸動脈;MCA的M1段; A1, precommunicating segment of the anterior cerebral artery. At the tip of the suction tube is the posterior part of the olfactory tract. D, intraoperative photograph after removal of the posteromedial orbital lobule and the rectus gyrus. 1, olfactory tract; 2, anterior cerebral artery in the interhemispheric fissure; 3, lenticulostriate arteries arising from the carotid bifurcation; M1, M1 segment of the MCA; A1, precommunicating segment of the anterior cerebral artery. E, postoperative MRI scan performed 5 days after surgery showed the resection of the frontobasal area, just anterior to the carotid artery bifurcation. (Images courtesy of AL Rhoton, Jr.)

圖23。A，右側翼點外側延伸入路的術中照片，描繪了島葉下界限溝(雙極鉗尖端之間)。1、顳葉;2、腦島;3,額葉。B，進入顳角後的術中照片。1、海馬頭部;2、脈絡膜叢、顳幹、中樞軸的M2段。雙極鉗已將Heschl回向後收攏。C，模擬手術入路的解剖解剖，見B. 1，顳上回; 2, head of the hippocampus; 3, Heschl’s gyrus; 4, insula. Asterisk, choroid plexus of the temporal horn. D, intraoperative photograph after a right pterional transsylvian selective amygdalohippocampectomy. 1, free edge of the tentorium; 2, dura mater of the floor of the middle fossa; 3, P2A segment of the posterior cerebral artery, and the choroid plexus of the temporal horn; 4, M2 segment of the MCA; 5, Heschl’s gyrus; III, oculomotor nerve. (Images courtesy of AL Rhoton, Jr.)

圖24。A，術中照片顯示右側杏仁核-海馬區經顳上回切除。右側顳角、顳上回和鉤骨已從外側裂和頸動脈池的蛛網膜上剝離。吸引管的尖端(左側)位於脈絡膜下點的正前方。雙極鉗的兩端都在顳角內。1、蛛網膜顳極;2、頸動脈(被蛛網膜覆蓋);3、MCA的M1段剛好在MCA膝前;4、島葉下限溝開始;5、顳上回; 6, choroid plexus of the temporal horn. Asterisk, anteromedial surface of the uncus that has been peeled off from the arachnoidal membrane of the carotid cistern. B, intraoperative photograph of the initial phase of a right hemisphere deafferentation (after splitting the sylvian fissure). 1, insula; M2, insular segment of the MCA. The arrowheads indicate anterior insular cleft. (Images courtesy of AL Rhoton, Jr.)