Superficial Sylvian Vein Research Articles

Microsurgical Resection of a Left Temporal Stem Cavernous Malformation Through Transsylvian Approach: 2-Dimensional Operative Video.

Cavernous malformations (CMs) are rare, often oligosymptomatic vascular lesions. Common manifestations include seizures and focal neurological deficits. Depending on the symptoms, location, size, and risk factors of bleeding, such as the presence of a developmental venous anomaly, the injury can be highly morbid. Hence, one can consider surgical resection. Deep and eloquently located CMs, such as those located in the temporal trunk, can be quite challenging and require an exact operative technique.1-7 We present a 27-year-old patient with a history of headaches that began two years ago and significantly worsened in the last month, associated with visual blurring, scotomas, nausea, phonophobia, and photophobia as well as paresthesias in the hands and perioral region. Imaging investigation revealed a CM in the temporal stem (Zabramski classification II). Owing to the risk of rebleeding and the young age, surgical resection was performed using a transsylvian approach to preserve the temporal cortex. We describe the technique applied and demonstrate the necessary care manipulating the distal sylvian fissure and the superficial sylvian veins. We also detail the anatomy of the temporal stem and the benefit of the transsylvian approach to preserve the white matter fibers that compose the temporal stem. The patient consented to the procedure and to the publication of his/her image. This study was approved by the Ethics Committee of our institution. Performed CM resection using the transsylvian pterional craniotomy technique, and it proceeded without complications. The postoperative period was also uneventful. The postoperative imaging demonstrated total resection of the cavernoma.

Basal vein of Rosenthal classification: the key to venous outflow of the deep sylvian fissure.

Mastery of sylvian fissure dissection is essential to access lesions within the deep basal cisterns. The deep sylvian vein and its tributaries play a major role during access to and beyond the carotid cistern through the sylvian fissure and determine the complexity of microdissection. Preserving the venous outflow during sylvian fissure dissection is the best reliable strategy to prevent postoperative venous strokes or venous hypertension. The authors report the role of the basal vein of Rosenthal (BVR) in the venous outflow pattern of the deep sylvian cistern. The authors analyzed 262 consecutive surgical cases involving sylvian fissure dissection from 2015 to 2017. Inclusion criteria were complete sylvian fissure dissection for the treatment of intracranial aneurysms. Exclusion criteria were giant size (aneurysm diameter > 24 mm), meningitis, subarachnoid hemorrhage within the sylvian cistern, absence of 4D CT angiography, and previous surgery. Retrospective radiological and operative video reviews were carried out to assess the association between the superficial sylvian vein and the BVR. The authors analyzed the course of the BVR and the patterns of venous drainage of the sylvian cistern. The surgical difficulty of sylvian fissure dissection was rated by the authors to study the operative significance of the venous patterns encountered. Two clinical cases are described to illustrate the proposed BVR classification. A total of 97 patients met the selection criteria. The most frequent type of BVR was immature (diameter < 0.5 mm, 68%). When the BVR was incompletely developed or absent (immature type), the deep sylvian veins drained through a middle sylvian vein in 70% of cases, requiring advanced sylvian fissure dissection techniques. However, when the BVR was completely developed (32%), the middle sylvian vein was found in a minority of cases (6%), which allowed for an unobstructed transsylvian corridor. Interrater and test-retest reliability of the surgical difficulty was greater than 0.9. Preoperative assessment of the BVR anatomy is key to predict the deep sylvian venous pattern. The authors provide objective evidence supporting the reciprocal relationship between the type of BVR and the presence of a middle sylvian vein and the deep sylvian venous outflow. An immature BVR should alert the neurosurgeon of the high likelihood of finding a complex deep venous pattern, which may drive surgical planning.

Sphenoparietal Sinus Transposition: Operative Technique for Optimizing Pretemporal Posterior Circulation Access While Preserving the Sylvian Venous Complex

Transsylvian approaches are a cornerstone of complex cranial operations, with wide applicability across cerebrovascular, skull base, and neuro-oncology operations. Deep lesions, especially those involving the basilar apex, midbrain, or interpeduncular fossa, require wide exposures that may be inhibited by the presence of a large complex of superficial sylvian veins (SSV) draining into the sphenoparietal sinus. This report describes technical and clinical aspects of the sphenoparietal sinus transposition (SPST) technique. Technical case report of the SPST technique, including a step-by-step neuroanatomic description, overview of common indications, clinical pearls and pitfalls, and illustrative case examples. Once the benefits of proceeding with SPST have been established, the maneuver is initiated with 2 stepwise dural incisions: an incision from lateral to medial along the lateral margin of the lesser sphenoid wing, followed by an orthogonal cut across the temporal pole down the middle fossa floor. The pretemporal dura is peeled off the lateral wall of the cavernous sinus, allowing mobilization of the SSV complex and temporal pole posteriorly without disrupting or straining the connection point at the sphenoparietal sinus. Illustrative case examples include a clip reconstruction of a basilar apex aneurysm for which earlier endovascular treatment had failed and microsurgical resection of a peduncular cavernous malformation. SPST is a simple but versatile technique with important applications in complex cranial surgery. By mobilizing the SSV complex together with its dural attachment, the transsylvian corridor can be markedly widened, allowing access to the basilar apex region and ventral midbrain.

Extravascular optical coherence tomography of cerebral vessel walls in vivo.

Evaluation of extravascular, microscope integrated OCT (iOCT) as an in vivo imaging modality of cerebral blood vessels and as an intraoperative imaging method. Microscope integrated optical coherence tomography of major cerebral arteries (n = 13) and superficial sylvian veins (n = 5) and one incidental cerebral vasospasm (n = 1) in (n = 10) patients. Post procedural analysis of OCT volume scans, microscopic images and videos during the time of scan as well as measurements of the diameter of vessel walls and its layers with an accuracy of 7.5 μm. iOCT was feasible during vascular microsurgical procedures. In all scanned arteries a clear delineation of the physiological three layered vessel wall composition could be achieved. Pathological arteriosclerotic alterations of cerebral artery walls could precisely be demonstrated. Major superficial cortical veins conversely presented a mono layered composition. First in vivo measurements of vascular mean diameters were possible. Cerebral artery walls showed a diameter of 296 μm, tunica externa 78 μm, media 134 μm and interna 84 μm. For the first time the microstructural composition of cerebral blood vessels could be illustrated in vivo. Due to an outstanding spatial resolution a clear definition of physiological and pathological characteristics was possible. Therefore, microscope integrated optical coherence tomography holds promise for basic research in the field of cerebrovascular arteriosclerotic diseases and for intraoperative guidance during microvascular surgery.

Cavernous Malformations: What They Have Taught Us.

Cavernous Malformations: What They Have Taught Us.

The Sphenoparietal Sinus Revisited: Anatomical and Histological Study With Application to Interventional Procedures and Skull Base Surgery.

Background The sphenoparietal sinus (SPS) is implicated in various clinical pathologies, specifically arteriovenous fistulasand venous sinus thrombosis. This study is aimed to better understand this venous structure of the skull base via histological examination. Methods Ten embalmed and latex-injected adult body donors' heads (20 sides)underwent microdissection of the SPSusing a surgical microscope. The entire dura on the underside of the lesser wing of the sphenoid bone encompassing the region known as the groove for the SPS was harvested from each body donor and submitted for histological analysis (H&E, Periodic acid-Schiff [PAS], Masson's Trichrome). Five leftand five right transverse sinuses were harvested and analyzed histologically as controls. Results A definitive SPS was identified in 14/20 (70%) of the latex-injected body donors. When present, the sinuses were classified as small, medium, or large. Tributaries included the middle meningeal veins, superficial Sylvian vein, and anterior temporal veins. All sinuses drained medially into the cavernous sinus. For the body donors analyzed histologically, 17 (85%) were consistent with a dural venous sinus and not a vein and were observed to have a rich nerve and arterial supply within their walls. The histological findings of the SPS were similar to those seen for the transverse sinus. The combined prevalence for the SPS in gross and histological body donors was 78%. Conclusions Our findings support the presence ofSPS in the majority of body donors. To our knowledge, this is the first histological study of the SPS.

Cerebral venous thrombosis in adolescence

Behçet's disease (BD) is a rare systemic vasculitis with multisystemic involvement. Neurological involvement, called neuro-Behçet's disease (NBD), mostly involves the central nervous system and cerebral venous thrombosis (CVT) is the predominant neurological manifestation in the pediatric age. A 12-year-old female with a past medical history of a CVT, without an identifiable etiology, was admitted with a five-day right fronto-orbital headache. Neuroimage showed a subacute thrombosis of a right superficial sylvian vein, with indirect signs of intracranial hypertension and no imaging signs of vasculitis. Prothrombotic screening and immunologic study were normal. She was started on acetazolamide and hypocoagulation with progressively improving. She had a history of frequent oral aphthae and an episode of a genital ulcer three months before admission. Pathergy test was negative. HLA-B51 was positive. She was diagnosed with NBD and started therapy with colchicine and infliximab. After discharge, the patient remains without symptoms, hypocoagulated, and on infliximab regimen, without complications to report. This case, only diagnosed in the second episode of CVT, is paradigmatic of the difficulty in establishing the diagnosis of BD.

Anatomical variations of dominant anastomotic veins in the superficial cortical venous system

BackgroundUnderstanding the anatomy of the anastomotic veins (AV) of the superficial cortical venous system (SCVS), viz. Superficial Sylvian vein (SSV) - also known as the superficial middle cerebral vein; vein of Labbe (VL) and vein of Trolard (VT), are imperative for neurosurgical procedures. This study aimed to investigate variant anatomical patterns of dominance of the AV, to elucidate the haemodynamically balanced SCVS, by reporting variations between the presence, diameter and dominant patterns of the AV. MethodsTwo hundred lateral angiograms were included, depicting left and right cerebral hemispheres of the same patient (n = 100 patients). Angiograms were analysed and variations recorded. Results were statistically compared against laterality, age, sex and ethnicity. ResultsPresence of the VL had the highest occurrence (96.5%), whereas the SSV and VT had an occurrence of 75.5% and 64.5%, respectively. This study reports presence of double veins of the AV: SSV (12.0%), VL (22.0%) and VT (19.5%). Furthermore, presence of a triple vein for each AV is reported. Diameters for the SSV, VL and VT were 1.99 ± 0.500 mm, 2.18 ± 0.579 mm and 2.14 ± 0.472 mm, respectively. Statistically significant relationships were established between diameters and the SSV, VL, VT and VT2 (double VT). Seven types of dominant patterns were recorded: Equilibrium; singular dominance of SSV, VL and VT; co-dominance of SSV/VL, SSV/VT and VL/VT. The Equilibrium dominant pattern of drainage had the highest occurrence (54.5%). ConclusionPatterns of dominance of these AV can aid the neurosurgeon in curbing the risk of iatrogenic injury and postoperative infarcts even after an otherwise successful surgery.

How do I: Venous reconstruction of accidentally injured superficial sylvian vein during the clipping of an unruptured cerebral aneurysm.

The transsylvian approach is a versatile treatment method for aneurysms of the anterior circulatory system. Studies have shown that sylvian veins run in various patterns, suggesting the need for dissection between veins to obtain appropriate surgical corridor. In case of inadvertent sylvian vein injury, serious complications such as venous congestion may occur. We herein describe the "side-to-side anastomosis reconstruction technique" of the resected superficial sylvian vein. This technique can be effective for the reconstruction of other cortical veins, and indocyanine green videoangiography was effective in determining the indications for venous reconstruction.

Assessment of collateral venous flow using temporary clip placement at ICG videoangiography.

As there are many collateral pathways between venous systems, intraoperative venous injury rarely induces venous infarction. In some patients, however, venous injury during microsurgical manipulation may cause acute and/or delayed serious complications. Although intraoperative evaluation using indocyanine green (ICG) videoangiography is very useful, it is difficult to assess the flow direction using this technique. A simple technique using temporary clips and ICG videoangiography was applied to assess the collateral venous pathway in 4 cases of surgical manipulation-related injury or occlusion of the main superficial Sylvian vein in patients with aneurysm. The flow direction and collateral pathway can be easily visualized after release of temporary occlusion. A collateral venous pathway can be evaluated with the present simple technique described here.

Impact of Cone-Beam Computed Tomography Angiography on Visualization of Sylvian Veins

A detailed understanding of the anatomy of Sylvian veins preoperatively is needed for venous-preserving Sylvian dissection. Better visualization of the venous architecture will facilitate surgical strategies for Sylvian dissection. This study evaluated and compared the image quality of the Sylvian veins and their tributaries using high-resolution cone-beam computed tomography angiography (CBCT-A) and three-dimensional computed tomography angiography (3D-CTA). Twenty-four patients who underwent 3D-CTA and CBCT-A as a preoperative simulation for clipping of unruptured intracranial aneurysms were retrospectively reviewed. In comparisons with intraoperative inspections, 3 raters evaluated the image quality of the Sylvian veins by 3D-CTA and CBCT-A with a 5-point scale. Visualization of the Sylvian veins and their tributaries by the 2 imaging modalities was compared using Wilcoxon signed rank test. CBCT-A showed superior image quality to 3D-CTA in evaluations of the discrimination of adjacent superficial Sylvian veins (2.8 ± 0.80 vs. 4.6 ± 0.37, P<0.0001), adjacent Sylvian veins at the sphenoid wing (3.1 ± 0.71 vs. 4.1 ± 0.56, P= 0.0001), and visualization of the tributaries of the Sylvian veins (2.5 ± 0.70 vs. 4.4 ± 0.37, P < 0.0001). CBCT-A was superior to 3D-CTA for visualizing the Sylvian veins and their tributaries. CBCT-A will provide important information on the anatomy of the Sylvian veins preoperatively.

NI-22 IMPROVED DELINEATION OF THE SUPERFICIAL CEREBRAL VENOUS SYSTEM IN BRAIN CT ANGIOGRAPHY BY ULTRAHIGH-RESOLUTION CT FOR ASSISTING BRAIN TUMOR SURGERY

BACKGROUNDIn brain CT angiography (CTA) for assisting brain tumor surgery, delineation of the superficial cerebral venous system is critical for selecting the optimal surgical approach. This delineation is, however, limited using conventional CT scanners, including an area-detector CT (ADCT) scanner, due to their insufficient spatial resolution. Since March 2017, a state-of-the-art ultrahigh-resolution CT (UHRCT) scanner has been clinically available to improve in- and through-plane spatial resolution compared with conventional CT scanners, mainly due to smaller slice thickness from 0.5 mm to 0.25 mm, larger channel number from 896 to 1792, and smaller x-ray focus from 0.9 x 0.8 mm to 0.4 x 0.5 mm.PurposeWe assessed usefulness of UHRCT to improve delineation of the superficial cerebral venous system in brain CTA for assisting brain tumor surgery compared with conventional ADCT.METHODSWe retrospectively enrolled patients with intra- and/or extra-axial brain tumors who underwent preoperative brain CTA for assisting brain tumor surgery by UHRCT or ADCT using our routine technique and generated the CTA to delineate the superficial cerebral venous system using the same technique. Two reviewers by consensus subjectively counted the number of the superficial sylvian veins and the cortical veins draining into these veins and the maximal bifurcation order of the cortical veins draining into the superior sagittal sinus. We compared these numbers and the maximal bifurcation order in the CTA between the UHRCT and ADCT groups using the intraoperative findings as the reference.RESULTSThe numbers and the maximal bifurcation order in the UHRCT group were significantly greater and more accurate than those in the ADCT group.CONCLUSIONSUse of UHRCT can be clinically useful for better delineating the superficial cerebral venous system in brain CTA and assisting brain tumor surgery.

Transcranial approach for surgical-combined-endovascular treatment of a cavernous dural arteriovenous fistula: the superficial sylvian vein route.

Transcranial approach for surgical-combined-endovascular treatment of a cavernous dural arteriovenous fistula: the superficial sylvian vein route.

Stereoelectroencephalography Using Magnetic Resonance Angiography for Avascular Trajectory Planning: Technical Report.

Stereoelectroencephalography (SEEG) requires high-quality angiographic studies because avascular trajectory planning is a prerequisite for the safety of this procedure. Some epilepsy surgery groups have begun to use computed tomography angiography and magnetic resonance T1-weighted sequence with contrast enhancement for this purpose. To present the first series of patients with avascular trajectory planning of SEEG based on magnetic resonance angiography (MRA). Thirty-six SEEG explorations for drug-resistant focal epilepsy were performed from January 2013 to December 2015. A retrospective analysis of this consecutive surgical series was then performed. Magnetic resonance imaging included MRA with a modified contrast-enhanced magnetic resonance venography (MRV) protocol with a short acquisition delay, which allowed simultaneous arterial and venous visualization. Our criteria for satisfactory MRA were the visualization of at least first-order branches of the angular artery, paracentral and calcarine artery, and third-order tributaries of the superficial Sylvian vein, vein of Labbe, and vein of Trolard. Thirty-four patients underwent 36 SEEG explorations with 369 electrodes carrying 4321 contacts. Contrast-enhanced MRA using the MRV protocol was judged satisfactory for SEEG planning in all explorations. Postoperative complications were not observed in our series of 36 SEEG explorations, which included 50 transopercular insular trajectories. MRA using an MRV protocol may be applied for avascular trajectory planning during SEEG procedures. This technique provides a simultaneous visualization of cortical arteries and veins without the need for additional radiation exposure or intra-arterial catheter placement.

Correct Plane of the Sylvian Vein Dissection for Middle Cerebral Artery Aneurysm Using Indocyanine Green Videoangiography

Preservation of the superficial Sylvian veins (SSVs) is essential to prevent neurologic deficits during Sylvian dissection. We describe an appropriate surgical approach for unruptured middle cerebral artery (MCA) aneurysms to preserve these veins by using indocyanine green videoangiography (ICG-VA). Between August 2014 and August 2015, we performed microsurgical clipping for 37 unruptured MCA aneurysms in 36 patients. We classified all of the cases into 3 types according to the location between the Sylvian fissure and the SSV. We defined 3 surgical approaches (frontosylvian, intersylvian, and temporo-sylvian) based on the SSV and investigated the proper surgical approach according to the type of case. In our study, most SSVs were located above the Sylvian fissure (fissure type, 64.9%). The SSV was located on the temporal lobe in 10 cases (temporal type) and on the frontal lobe in 3 cases (frontal type). The frontosylvian approach (splitting between the SSV and frontal lobe) was performed in all of the patients with temporal type; the temporo-sylvian approach (splitting between the SSV and temporal lobe) was performed in all of the patients with frontal type and single SSV of fissure type. The intersylvian approach (splitting between the frontal and temporal SSV, or among multiple SSVs) was successfully performed in the patients with double or multiple SSVs of fissure type. No venous complications occurred that were related to the surgical approach. Correct dissection strategy using intraoperative ICG-VA is greatly useful to define the optimal surgical approach without vein injury.

Abstract WP90: Intraoperative Premature Rupture of Middle Cerebral Artery Aneurysms: Risk Factors and Sphenoid Ridge Proximation Sign

Object: The investigation of surgical cases of a ruptured middle cerebral artery (MCA) aneurysm to identify the risk factors of an intraoperative premature rupture. Methods: Based on an 8-year period and among 927 patients with a ruptured intracranial aneurysm, the medical records of 182 consecutive patients with a ruptured MCA aneurysm were examined for cases of a premature rupture, and the risk factors were then investigated. The considered risk factors included: the patient age, gender, WFNS clinical grade, modified Fisher grade, presence of an ICH, frontal ICH, temporal ICH, volume of the ICH, maximum diameter of the ruptured MCA aneurysm, length of the pre-aneurysmal M1 segment between the carotid bifurcation and the MCA aneurysm, and the presence of a sphenoid ridge proximation sign. The use of axial source images and a three-dimensional reconstruction of the brain CTA revealed a sphenoid ridge proximation sign based on the spatial proximation between a potential rupture point of the MCA aneurysm and the cortical arachnoid of the sphenoidal sylvian fissure, adjacent superficial sylvian veins, and the sphenoid ridge. Results: A total of 11 patients (6.0%) suffered a premature rupture of the MCA aneurysm during surgery. The premature rupture occurrences were classified according to the stage of the surgery as follows: 1) craniotomy and dural opening (n = 1), 2) aspiration or removal of the ICH (n = 1), 3) retraction of the frontal lobe (n = 1), 4) dissection of the sphenoid segment of the sylvian fissure to access the proximal vessel (n = 4), and 5) peri-aneurysmal dissection (n = 4). Univariate and multivariate analyses revealed that the presence of a sphenoid ridge proximation sign, a frontal ICH associated with the ruptured MCA aneurysm, and the length of the pre-aneurysmal M1 segment were all statistically significant risk factors for a premature rupture of a MCA aneurysm. Conclusions: Patients exhibiting a sphenoid ridge proximation sign, the presence of a frontal ICH, and/or a short pre-aneurysmal M1 segment are high-risk patients for an intraoperative premature rupture of a MCA aneurysm. Such high-risk MCA aneurysms have a superficial location close to the arachnoid in the sphenoidal compartment of the sylvian fissure and have a rupture point directing anteriorly.

Safe and accurate sylvian dissection with the use of indocyanine green videoangiography.

Background:Sylvian dissection is an essential microneurosurgical skill for neurosurgeons. The safe and accurate opening of the sylvian fissure is desirable for a good prognosis.Methods:The aim of this report is to demonstrate the use of indocyanine green (ICG) videoangiography to recognize the superficial sylvian vein (SSV) and thus enable a wide opening of the sylvian fissure, especially in patients with subarachnoid hemorrhage (SAH).Results:The small tributary flowing into the SSV was distinguishable from a passing one, which deeply entered the insula. In addition, an entering point of a tributary to the SSV, which ran perpendicular to the insula, was occasionally determined. SSV, which was barely discernable in a reddish SAH involving the sylvian fissure, was clearly demarcated using ICG videoangiography. Two representative cases of sylvian dissection are herein presented.Conclusion:The performance of ICG videoangiography before sylvian dissection is a simple and useful method for identifying a vital approach route for safe and accurate sylvian dissection, and it reduces the risk of causing any accidental injury to the veins in the sylvian fissure.

Indocyanine Green (ICG) Videoangiography-Guided Dissection of the Sylvian Fissure on the Transsylvian Approach: Technical Note

The transsylvian approach is a standard method of approach for anterior circulation aneurysms or paraclinoid tumors. Care must be taken, however, to avoid inadvertent obliteration of sylvian veins to prevent postoperative brain swelling and venous infarction. Sometimes, the superficial sylvian veins have complex connections or are not visible because of the thickness of the arachnoid membrane, especially in the case of subarachnoid hemorrhage (SAH). The present report describes a simple method to dynamically visualize the sylvian vein via indocyanine green (ICG) angiography for the purposes of appropriately wide dissection of the sylvian fissure. Before dissection of the sylvian fissure and after opening the dura mater, a bolus of ICG is administered intravenously. ICG videoangiography is used for dynamic venography at 10 seconds after the depiction of branches of the middle cerebral artery. Clear documentation of the sylvian vein was obtained via ICG videoangiography, even in cases of SAH with ambiguous anatomical topography attributable to clot under the superficial arachnoid membrane. ICG was able to differentiate between the sylvian veins of the frontal and temporal lobes, which allowed wide dissection of the sylvian fissure while preserving the veins. ICG videoangiography is an easy and useful method for identifying the connections and tributaries of the superficial sylvian veins from a transsylvian approach. This method allows wide opening of the sylvian fissure while preserving the sylvian veins.

Venous-Preserving Sylvian Dissection

The Sylvian fissure has been dissected through the frontal side of the superficial Sylvian veins with sacrifice of the tributaries of the frontal superficial Sylvian vein, which may lead to venous infarction. In addition, disturbed venous drainage makes the brain susceptible to brain retraction. Therefore, preservation of the vein is essential in modern neurosurgery to decrease morbidity. We describe the technical nuances of Sylvian dissection with an emphasis on preserving the veins. The arachnoid between the frontal and temporal superficial Sylvian veins is divided as to enter the fissure. After the deep part in the Sylvian fissure is reached, the inside of the fissure is dissected along the "microvascular Sylvian fissure," the temporal side of the frontal vessels or the frontal side of the temporal vessels. The Sylvian fissure is dissected in a deep-to-superficial and posterior-to-anterior fashion ("paperknife technique") up to the skull base. The frontal superficial Sylvian vein usually tethers the brain to the dura, restricting the surgical corridor when approaching deep lesions. Peeling off the arachnoid that wraps this vein ("denude technique") allows the vein to stretch. Keeping the proper dissection plane ("microvascular Sylvian fissure") is crucial to preserve the veins. The "paperknife technique" makes the division of the frontal and temporal lobe easier. The "denude technique" provides a wider space between the frontal lobe and the skull base. These techniques make it possible to obtain a sufficiently wide surgical corridor to the basal cistern without sacrificing the veins and their tributaries.

Microsurgical anatomy of the central lobe.

The central lobe consists of the pre- and postcentral gyri on the lateral surface and the paracentral lobule on the medial surface and corresponds to the sensorimotor cortex. The objective of the present study was to define the neural features, craniometric relationships, arterial supply, and venous drainage of the central lobe. Cadaveric hemispheres dissected using microsurgical techniques provided the material for this study. The coronal suture is closer to the precentral gyrus and central sulcus at its lower rather than at its upper end, but they are closest at a point near where the superior temporal line crosses the coronal suture. The arterial supply of the lower two-thirds of the lateral surface of the central lobe was from the central, precentral, and anterior parietal branches that arose predominantly from the superior trunk of the middle cerebral artery. The medial surface and the superior third of the lateral surface were supplied by the posterior interior frontal, paracentral, and superior parietal branches of the pericallosal and callosomarginal arteries. The venous drainage of the superior two-thirds of the lateral surface and the central lobe on the medial surface was predominantly through the superior sagittal sinus, and the inferior third of the lateral surface was predominantly through the superficial sylvian veins to the sphenoparietal sinus or the vein of Labbé to the transverse sinus. The pre- and postcentral gyri and paracentral lobule have a morphological and functional anatomy that differentiates them from the remainder of their respective lobes and are considered by many as a single lobe. An understanding of the anatomical relationships of the central lobe can be useful in preoperative planning and in establishing reliable intraoperative landmarks.