White Matter-Governed Superior Frontal Sulcus Surgical Paradigm: A Radioanatomic Microsurgical Study-Part I.

Abstract

Frontal subcortical and intraventricular pathologies are traditionally accessed via transcortical or interhemispheric-transcallosal corridors. To describe the microsurgical subcortical anatomy of the superior frontal sulcus (SFS) corridor. Cadaveric dissections were undertaken and correlated with magnetic resonance imaging/diffusion-tensor imaging-Tractography. Surgical cases demonstrated clinical applicability. SFS was divided into the following divisions: proximal, precentral sulcus to coronal suture; middle, 3-cm anterior to coronal suture; and distal, middle division to the orbital crest. Anatomy was organized as layered circumferential rings projecting radially towards the ventricles: (1) outer ring: at the level of the SFS, the following lengths were measured: (A) precentral sulcus to coronal suture=2.29 cm, (B) frontal bone projection of superior sagittal sinus (SSS) to SFS=2.37 cm, (C) superior temporal line to SFS=3.0 cm, and (D) orbital crest to distal part of SFS=2.32 cm; and (2) inner ring: (a) medial to SFS, U-fibers, frontal aslant tract (FAT), superior longitudinal fasciculus I (SLF-I), and cingulum bundle, (b) lateral to SFS, U-fibers, (SLF-II), claustrocortical fibers (CCF), and inferior fronto-occipital fasciculus, and (c) intervening fibers, FAT, corona radiata, and CCF. The preferred SFS parafascicular entry point (SFSP-EP) also referred to as the Kassam-Monroy entry point (KM-EP) bisects the distance between the midpupillary line and the SSS and has the following coordinates: x=2.3 cm (lateral to SSS), y≥3.5 cm (anterior to CS), and z=parallel corona radiata and anterior limb of the internal capsule. SFS corridor can be divided into lateral, medial, and intervening white matter tract segments. Based on morphometric assessment, the optimal SFSP-EP is y≥ 3.5cm, x=2.3 cm, and z=parallel to corona radiata and anterior limb of the internal capsule.