Subcortical Neurosurgery Open and Parafascicular Channel

Based Approaches for Subcortical and Intraventricular

Lesions

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Preface

Access to subcortical lesions has been the topic of numerous surgical and technical
innovations since the beginning of neurosurgery. The concept for this textbook
evolved as a result of rapid innovation within the field of subcortical surgery, and the
integrated efforts of numerous scientists, biomedical engineers, neurosurgeons, and
industry partners who collectively defined the subcortical space as the “final fron-
tier” of neurological surgery in need for more accurate, precise, and effective surgi-
cal innovation.
The wide assortment of techniques developed to navigate the inherent challenges
presented by the multitude of etiologies encountered in the subcortical space and
the idiosyncrasies related to their location within the parenchymal substance and
ventricular system traditionally failed to recognize the immense complexity of the
subcortical space, which has only been elucidated recently thanks to advances in
neuro-imaging (particularly diffusion tensor imaging), neuro-navigation, functional
neuro-anatomy, surgical instrumentation and technique, and refinement of indica-
tions and outcomes.
A more sophisticated understanding of complex subcortical structures, the intri-
cate relationships among them, and their plasticity under pathologic conditions was
finally realized through our ability to image, map, and understand their functional
correlates, resulting in a collective call for surgically applicable tools for identifying
and sparing this critical anatomy to maximally preserve neurological function.
This paradigm shift in subcortical surgery views all brain tissue as eloquent
tissue, and maintains the uncompromised principle of only traversing brain tissue
on the way to a neurosurgical target with minimal collateral damage. The judicious
application of this principle translated into novel approaches for a variety of subcor-
tical and intraventricular lesions, ranging from intracerebral hemorrhages (ICH) to
subcortical tumors and intraventricular colloid cysts, among many others. The con-
cept for this textbook emerged from collaborations within the Subcortical Surgery
Group and cooperation with key industry partners in an effort to expeditiously push
this cutting edge forward.
We, the editors, would like to thank the many contributing authors of this text-
book, who are each and all world experts on the front lines of the rapidly advancing

v
vi Preface

field of subcortical surgery. This compendium of high-yield knowledge and surgical

pearls has been selectively curated by the editorial team to provide the reader with
a comprehensive understanding pertaining to the anatomy, neuro-imaging, existing
technology, and surgical techniques and outcomes associated with subcortical neu-
rosurgery. The chapters provide focused explanations of open and minimally inva-
sive, port-based approaches to the subcortical and intraventricular spaces, case
examples, and strategies to deal with selected pathology and intraoperative
complications.
It is our collective hope that this textbook will provide readers with a comprehen-
sive and one-stop reference for subcortical anatomy and surgery. It is also our hope
that this book will be made obsolete soon, in the sense that this will only reflect the
unprecedented pace at which the field and technology within subcortical surgery is
evolving. We hope that readers derive significant benefit from the unparalleled work
provided by the authorship of this book.

Los Angeles, CA, USA Gabriel Zada

Atlanta, GA, USA Gustavo Pradilla
Little Rock, AR, USA J. D. Day
Contents

1 
The Subcortical Space: Anatomy of Subcortical White Matter����������    1
Sandip S. Panesar, Kumar Abhinav, Peizhi Zhou, Yuanzhi Xu,
and Juan Fernandez-Miranda
2 
The Ventricular System: Anatomy and Common Lesions ������������������   19
Robert A. Scranton and Aaron Cohen-Gadol
3 
Advanced Neuroimaging of the Subcortical Space:
Connectomics in Brain Surgery��������������������������������������������������������������   29
Nicholas B. Dadario and Michael E. Sughrue
4 
Advanced Neuroimaging of the Ventricular System����������������������������   49
Paul E. Kim
5 The Evolution of Trans-Sulcal Channel-­Based
Parafascicular Surgery����������������������������������������������������������������������������   67
Thiago Albonette Felicio and Daniel M. Prevedello
6 Open Approaches to Intraventricular Tumors,
Colloid Cysts, and the Subcortical Space����������������������������������������������   79
Aditya Kondajji, Prasanth Romiyo, Courtney Duong,
Won Kim, and Isaac Yang
7 
Traditional Open and Neuro-Endoscopic Approaches
to Intraventricular Pathology ����������������������������������������������������������������   99
Joshua Prickett, Cristian Gragnaniello, Juan Altafulla,
and Zachary N. Litvack
8 
Trans-sulcal, Channel-Based Parafascicular Surgery:
Basic Concepts and a General Overview ���������������������������������������������� 113
Sean P. Polster, David Satzer, and Julian Bailes

vii
viii Contents

9 
Trans-sulcal, Channel-Based Parafascicular Surgery
for Subcortical and Intraventricular Lesions:
Instruments and Technical Considerations ������������������������������������������ 121
Mohamed A. R. Soliman, Claudio Cavallo, Sirin Gandhi,
Xiaochun Zhao, and Mohamed A. Labib
10 
Standard Parafascicular Approaches to Subcortical Regions ������������ 137
J. Manuel Revuelta Barbero, David Bray, and Gustavo Pradilla
11 
Trans-sulcal, Minimally Invasive Parafascicular
Surgery for Brain Metastases ���������������������������������������������������������������� 153
Joshua Bakhsheshian, Ben Allen Strickland, and Gabriel Zada
12 
Minimally Invasive Parafascicular Surgery (MIPS)
for Primary and Metastatic Brain Neoplasms�������������������������������������� 165
J. D. Day
13 
Trans-sulcal, Channel-Based Parafascicular Biopsy Techniques�������� 193
Evan D. Bander and Rohan Ramakrishna
14 
Trans-sulcal, Channel-Based Parafascicular Surgery
for Colloid Cysts�������������������������������������������������������������������������������������� 205
Lina Marenco-Hillembrand and Kaisorn L. Chaichana
15 
Trans-sulcal, Channel-Based Parafascicular Surgery
for Intracerebral Hematoma������������������������������������������������������������������ 217
Rima Sestokas Rindler and Gustavo Pradilla
16 
Trans-sulcal, Channel-Based Parafascicular Surgery
for Cavernous Angiomas and Other Vascular Lesions ������������������������ 231
Benjamin B. Whiting and Mark D. Bain
17 
Surgical Resection of Intraventricular Tumors Using
a Minimally Invasive Parafascicular (MIP) Approach
with a Navigated Tubular Retractor System ���������������������������������������� 237
Jonathan Weyhenmeyer, Robert A. Scranton, Charles Kulwin,
and Mitesh V. Shah
18 Future Directions ������������������������������������������������������������������������������������ 251
Gabriel Zada, Gustavo Pradilla, and J. D. Day

Index�������������������������������������������������������������������������������������������������������������������� 253
Contributors

Kumar Abhinav, FRCS (SN) Stanford Neurosurgical Training and Innovation

Center, Stanford University, Stanford, CA, USA
Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Center for
Skull Base and Pituitary Neurosurgery, Southmead Hospital, Bristol, UK
Department of Neurosurgery, Stanford University School of Medicine,
Stanford, CA, USA
Juan Altafulla, MD Jose Domingo de Obaldia Hospital, Department of Surgery,
Panama, Panama
Julian Bailes, MD NorthShore University Health Systems, Department of
Neurosurgery, Evanston, IL, USA
Mark D. Bain, MD Department of Neurosurgery, Cleveland Clinic Foundation,
Cleveland, OH, USA
Joshua Bakhsheshian, MD University of Southern California, Department of
Neurosurgery, Los Angeles, CA, USA
Evan D. Bander, MD NewYork-Presbyterian Hospital, Weill Cornell Medicine,
Department of Neurosurgery, New York, NY, USA
J. Manuel Revuelta Barbero, MD, PhD Department of Neurosurgery, Emory
University, Atlanta, GA, USA
David Bray, MD Department of Neurosurgery, Emory University School of
Medicine, Atlanta, GA, USA
Claudio Cavallo, MD Vanderbilt University Medical Center, Department of
Neurosurgery, Nashville, TN, USA
Kaisorn L. Chaichana, MD, FAACS, FAANS Department of Neurosurgery,
Mayo Clinic Florida, Jacksonville, FL, USA

ix
x Contributors

Aaron Cohen-Gadol, MD The Neurosurgical Atlas, Carmel, IN, USA

Department of Neurological Surgery, Indiana University, Indianapolis, IN, USA
J. D. Day, MD Department of Neurosurgery, University of Arkansas for Medical
Sciences, Little Rock, AR, USA
Nicholas B. Dadario, BS Robert Wood Johnson Medical School, Rutgers
University, New Brunswick, NJ, USA
Courtney Duong, BS David Geffen School of Medicine, Department of
Neurosurgery, Los Angeles, CA, USA
Thiago Albonette Felicio, MD The Ohio State University Wexner Medical Center,
Department of Neurological Surgery, Columbus, OH, USA
Juan Fernandez-Miranda, MD Stanford Neurosurgical Training and Innovation
Center, Stanford University, Stanford, CA, USA
Department of Neurosurgery, Stanford University School of Medicine,
Stanford, CA, USA
Sirin Gandhi, MD St. Joseph’s Hospital and Medical Center, Department of
Surgery, Phoenix, AZ, USA
Cristian Gragnaniello, MD, PhD Department of Neurosurgery, UT Health San
Antonio, San Antonio, TX, USA
Paul E. Kim, MD Division of Neuroradiology, Department of Radiology,
University of Southern California Keck School of Medicine, Los Angeles, CA, USA
Won Kim, MD Ronald Reagan UCLA Medical Center, Department of
Neurosurgery, Los Angeles, CA, USA
Aditya Kondajji, BS Ronald Reagan UCLA Medical Center, Department of
Neurosurgery, Los Angeles, CA, USA
Charles Kulwin, MD Goodman Campbell Brain and Spine, Carmel, IN, USA
Mohamed A. Labib, MD Department of Neurosurgery, University of Maryland
Medical Center, Baltimore, MD, USA
Zachary N. Litvack, MD, MCR Neuroscience Institute, Swedish Medical Center,
Seattle, WA, USA
Lina Marenco-Hillembrand, MD Department of Neurosurgery, Mayo Clinic
Florida, Jacksonville, FL, USA
Sandip S. Panesar Stanford Neurosurgical Training and Innovation Center,
Stanford University, Stanford, CA, USA
Sean P. Polster, MD University of Chicago, Department of Neurosurgery,
Chicago, IL, USA
Contributors xi

Gustavo Pradilla, MD, FAANS Neurological Surgery, Emory University School

of Medicine, Atlanta, GA, USA
Daniel M. Prevedello, MD The Ohio State University Wexner Medical Center,
Department of Neurological Surgery, Columbus, OH, USA
Joshua Prickett, DO Aiken Regional Medical Centers, Department of Surgery,
Aiken, SC, USA
Rohan Ramakrishna, MD NewYork-Presbyterian Hospital, Weill Cornell
Medicine, Department of Neurological Surgery, New York, NY, USA
Rima Sestokas Rindler, MD The Mayo Clinic, Department of Neurosurgery,
Rochester, MN, USA
Prasanth Romiyo, BS Tina & Fred Segal Brain Tumor and Skull Base Research
Fellow, Ronald Reagan UCLA Medical Center, Department of Neurosurgery, Los
Angeles, CA, USA
David Satzer, MD University of Chicago, Department of Neurosurgery,
Chicago, IL, USA
Robert A. Scranton, MD Department of Neurosurgery, Indiana University School
of Medicine, Indianapolis, USA
Mitesh V. Shah, MD Department of Neurosurgery, Indiana University School of
Medicine, Indianapolis, USA
Mohamed A. R. Soliman, MD, MSc, PhD Faculty of Medicine, Department of
Neurosurgery, Cairo University, Cairo, Egypt
Department of Neurosurgery, Jacobs School of Medicine and Biomedical Science,
University at Buffalo, New York, NY, USA
Ben Allen Strickland, MD Los Angeles County General Hospital, Department of
Neurosurgery, Los Angeles, CA, USA
Michael E. Sughrue, MD Department of Neurosurgery, Prince of Wales Hospital,
Sydney, NSW, Australia
Jonathan Weyhenmeyer, MD Department of Neurosurgery, Indiana University
School of Medicine, Indianapolis, IN, USA
Benjamin B. Whiting, MD Department of Neurosurgery, Cleveland Clinic
Foundation, Cleveland, OH, USA
Yuanzhi Xu, MD Stanford Neurosurgical Training and Innovation Center, Stanford
University, Stanford, CA, USA
Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan
University, Shanghai, China
xii Contributors

Isaac Yang, MD Ronald Reagan UCLA Medical Center, Department of

Neurosurgery, Los Angeles, CA, USA
Gabriel Zada, MD, MS Keck Hospital, Neurological Surgery, Los
Angeles, CA, USA
Xiaochun Zhao, MD OU Health, Department of Neurosurgery, Oklahoma
City, OK, USA
Peizhi Zhou, MD Department of Neurosurgery, West China Hospital of Sichuan
University, Chengdu, City, China
Chapter 1
The Subcortical Space: Anatomy
of Subcortical White Matter

Sandip S. Panesar, Kumar Abhinav, Peizhi Zhou, Yuanzhi Xu,

and Juan Fernandez-Miranda

Introduction

A thorough understanding of subcortical white matter anatomy is critical for the

neurosurgeon. Subcortical white matter consists of myelinated axon fibers arranged
in anatomically relevant discrete bundles or fascicles. The subcortical white matter

S. S. Panesar
Stanford Neurosurgical Training and Innovation Center, Stanford University,
Stanford, CA, USA
K. Abhinav
Stanford Neurosurgical Training and Innovation Center, Stanford University,
Stanford, CA, USA
Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Center for Skull Base
and Pituitary Neurosurgery, Southmead Hospital, Bristol, UK
Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
e-mail: [email protected]
P. Zhou
Department of Neurosurgery, West China Hospital of Sichuan University,
Chengdu City, China
Y. Xu
Stanford Neurosurgical Training and Innovation Center, Stanford University,
Stanford, CA, USA
Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan
University, Shanghai, China
J. Fernandez-Miranda (*)
Stanford Neurosurgical Training and Innovation Center, Stanford University,
Stanford, CA, USA
Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2022 1

G. Zada et al. (eds.), Subcortical Neurosurgery,
https://doi.org/10.1007/978-3-030-95153-5_1
2 S. S. Panesar et al.

fasciculi are anatomo-functionally categorized into projection, association, limbic,

commissural, or U-fiber systems. Aside from the U-fiber system, which, by defini-
tion, consists of short cortico-cortical fibers between adjacent gyri, the other sys-
tems consist of both long- and short-range fasciculi assuming either intra- or
interlobar (or interhemispheric, if commissural) courses [1].
Traditionally, anatomical descriptions of human subcortical white matter anat-
omy came from postmortem dissection techniques. These descriptions persisted
until the latter twentieth century until the introduction of diffusion magnetic reso-
nance imaging (MRI) tractography. Though historically important as a foundation
for anatomical understanding, postmortem dissection suffers from several key limi-
tations including substantial time taken to acquire, prepare, and dissect specimens,
permitting few subjects per study; a loss of anatomical integrity due to preparation;
destruction of specimens due to a lateral-medial dissection approach; and the inabil-
ity to accurately determine cortical connectivity. Radioisotope tracer injection in
nonhuman primates is considered the “gold standard” approach for studying white
matter cortical connectivity. Nevertheless, as these require sacrifice of the study
subject, they cannot be utilized in humans. Moreover, translating simian neuroana-
tomical findings to humans is problematic, however, due to the evolutionary diver-
gence between species.
MRI tractography is a technique of measuring the diffusion properties of water
confined within myelinated axons noninvasively and, most importantly, in vivo [2].
The introduction of tractography toward the 1990s permitted study of white matter
in large numbers of healthy and diseased subjects. Most importantly for the neuro-
surgeon, tractography permits the study of white matter architecture affected by the
presence of space-occupying lesions [3, 4]. By visualizing white matter tract dis-
placement, disruption, or infiltration by tumors or other pathologies, the neurosur-
geon may tailor their approach to the lesion so as to cause minimal damage to the
perilesional white matter while safely maximizing the extent of resection. The
trade-off between the extent of resection and functional outcome may therefore be
optimized, especially when preoperative tractography is utilized in conjunction
with other functional adjuncts such as functional imaging or use of awake craniot-
omy. Intraoperative electrical stimulation (IES), in this respect, is considered a gold
standard and also affords a unique opportunity to further study and understand the
function of different white matter tracts.

Projection System

The projection fasciculi subserve core sensorimotor functionality. These include the
ascending sensory pathways, the descending motor pathways, and the audiovisual
afferents (Fig. 1.1a).
1 The Subcortical Space: Anatomy of Subcortical White Matter 3

a b

c d

Fig. 1.1 (a) Tractography of the projection white matter tracts. Left sagittal view. The claustro-­
cortical system (light blue) lies superficial to the cortical terminations of the corticospinal tracts
(red). Rostrally-caudally are the acoustic radiations (gray) and optic radiations (purple). (b)
Dissection of a postmortem specimen. View of the left hemisphere following removal of the gray
matter, U-fibers, and superficial association system to reveal the claustrum (Claust.) lying within
the extreme capsular structures. (c) Another view of the left hemisphere from a postmortem speci-
men. More white matter has been removed from the extreme and external capsules to reveal the
underlying optic radiations (OR) and acoustic radiations (AR). (d) In this view of a postmortem
left-hemisphere, the corticospinal tracts (CST) have been exposed

Claustro-Cortical Fibers

The claustrum is a collection of peri-insular gray matter lying in between the

extreme and external capsules. Projection fibers fan out in a sheetlike arrangement
from the claustrum and travel to the superior frontal, precentral, postcentral, and
posterior parietal cortices. The claustro-cortical fiber system lies dorsal to the infe-
rior fronto-occipital and uncinate fasciculi within the external capsule (Fig. 1.1b).

Optic Radiations

The optic radiations are the final portion of the visual pathways. They begin at
the lateral geniculate nucleus of the thalamus before radiating anterolaterally
into the substance of the temporal lobe. As they travel anteriorly, they are medial to
4 S. S. Panesar et al.

the medial wall of the temporal horn of the lateral ventricle. The optic radiations
then turn sharply, continuing to fan out while passing over the roof of the anterior
temporal horn before assuming a position lateral to the lateral wall of the temporal
horn and continuing posteriorly. The optic radiations remain lateral to the lateral
wall of the temporal horn, traversing most medially within the sagittal stratum into
the occipital lobe, where they terminate on either side of the calcarine sulcus. Like
all white matter, the optic radiations are anatomo-functionally organized, with the
upper division (Baum’s loop) carrying sensory information from the inferior visual
quadrants and the lower division (Meyer’s loop) carrying sensory information from
the superior visual quadrants. Lesions to the optic radiations produce characteristic
visual field deficits depending upon the location of the lesion (Fig. 1.1c).

Acoustic Radiations

The acoustic radiations originate from the medial geniculate nucleus of the thala-
mus. They assume a tortuous S shape and pass medially-laterally as they travel into
the dorsal temporal lobe. From the medial geniculate nucleus, the acoustic radia-
tions first pass underneath the optic radiations. They pass upward via internal cap-
sule and backward along the inferior sulcus of the insula, into the temporal lobe,
where they pass perpendicular to the fibers of the temporal stem (inferior fronto-­
occipital, inferior longitudinal, and uncinate fasciculi). They terminate at Heschl’s
gyrus of the temporal lobe, which lies on its dorsal surface, within the Sylvian fis-
sure (Fig. 1.1c).

Geniculate Motor Fibers

The geniculate tracts transmit motor information to the peripheral nervous system.
They consist of two functionally distinct fiber populations: corticospinal (controlling
limb movements) and corticobulbar (controlling cranial motor function) projections.
The geniculate fibers all originate in layer V pyramidal neurons of the premotor,
motor, and supplementary motor cortices. At their origin, they are fanned out radially,
along the motor strip, which is bounded dorsally and medially by the sagittal sulcus,
and ventrally and laterally by the Sylvian fissure. The dorsomedially originating fibers
travel caudally, while the ventrolaterally originating fibers travel medially and over
the dorsomedial fibers as they converge at the corona radiata. The geniculate tracts
therefore assume a “twisted” arrangement. After passing through the genu of the
internal capsule, the bundle travels into the brainstem via the crus cerebri. The corti-
cospinal projections lie anterior to the corticobulbar projections. In the brainstem,
corticospinal fibers pass into the medulla via the pons, prior to decussating at the pyra-
mids and continuing as the lateral corticospinal tract. At the level of the brainstem, the
corticobulbar fibers synapse upon the appropriate cranial nerve nuclei (Fig. 1.1d).
1 The Subcortical Space: Anatomy of Subcortical White Matter 5

Corticocerebellar Fibers

The corticocerebellar fibers transmit information to and from the cerebellum and its
nuclei. They originate from all cortical areas and can be classified according to their
site of origin from the hemispheric lobes. These fibers generally include the pontine
nuclei as a waypoint between the cerebral cortices and the cerebellum and are also
known as the corticopontocerebellar fibers. From their cortical origins, they all
travel caudally via the internal capsule and crus cerebri in an organized fashion. For
example, fibers originating from the prefrontal and frontal cortices travel most ante-
riorly within the internal capsule, whereas fibers originating from the occipital cor-
tex travel most posteriorly. Corticopontocerebellar fibers from all lobes converge
within the posterior limb of the internal capsule before passing via the crus cerebri
to the pons where they decussate. The corticopontocerebellar fibers henceforth
travel via the middle cerebellar peduncle to their cerebellar terminations.

Sensory Projection Fibers

The dorsal columns of the spinal cord carrying vibration, proprioception, fine touch,
and discriminative sensory information ascend the spinal cord, synapsing upon the
gracile (below T6 level) and cuneate (above T6 level) nuclei within the medulla.
From these medullary nuclei, the medial lemniscus pathway decussates and ascends
via the mesencephalon to the thalamus, synapsing upon the ventral posterior nucleus
of the thalamus. The anterolateral system carries sensations of crude touch and pres-
sure (anterior spinothalamic tract) and pain and temperature (lateral spinothalamic
tract). These enter the spinal cord and ascend briefly (1–2 levels) before decussating
and travelling to the various thalamic nuclei. The lateral spinothalamic tract travels
through the brainstem via the spinal lemniscus and synapses at the ventroposterolat-
eral thalamic nucleus. The anterior spinothalamic tract joins the medial lemniscus
to travel to the ventral posterior thalamic nucleus. From the thalamus, the sensory
projections travel to the postcentral gyrus of the parietal lobe via the thalamocortical
radiations, which pass through the internal capsule. Some thalamocortical projec-
tions travel to the limbic system via the cingulum.

Projection System: Surgical Considerations

Damage to motor pathways may result in partial or complete hemiparesis. Likewise,

damage to the optic radiations (e.g., during temporal lobe resections) can produce
visual field deficits. Several methods exist to delineate their course both preopera-
tively and intraoperatively. Preoperatively, functional methods such as functional
MRI (fMRI) or magnetoencephalography (MEG) may be used. These techniques
6 S. S. Panesar et al.

permit localization of functional cortex specific to particular tasks. Nevertheless,

they cannot reliably demonstrate the subcortical course of white matter tracts.
Tractography is able to reliably demonstrate corticospinal projections from their
cortical origin to the medullary level (or below) and has thus become commonplace
for preoperative localization [3]. It can also demonstrate the optic radiations; how-
ever, some algorithms have difficulty reproducing the full extent of Meyer’s loop
due to its sharp turn over the anterior horn. Efforts have been made to integrate both
fMRI and MEG with tractography, with the functional techniques utilized to create
regions of interest from which fiber tracking algorithms may be launched [5, 6].
This is particularly useful when considering that lesions may grow within or in
close proximity to eloquent white matter. In these instances, delineation of white
matter anatomy is critical for presurgical planning. Intraoperative electrical stimula-
tion (IES) is also a valuable tool [7] as it permits direct intraoperative functional
localization, which may ultimately determine resection extent. The complementary
use of all aforementioned techniques may ultimately enhance both preoperative and
intraoperative anatomo-functional localization.

Limbic System

The limbic system subserves emotional and memory functionality. It consists of

both large and small white matter fasciculi which interconnect subcortical gray mat-
ter nuclei and the parahippocampal regions. The primary limbic white matter com-
ponents are the cingulum and fornix; however, many smaller tracts also interconnect
the telencephalon with the diencephalon and mesencephalon (Fig. 1.2a).

Cingulum

The cingulum is the long white matter tract travelling parasagittally on either side
of the central sulcus. It originates in the orbitofrontal regions, ventral to the rostrum
of the corpus callosum, travelling first anteriorly, and then curving around the genu,
to eventually lie dorsal to the corpus callosum along its anteroposterior course. At
the posterior sagittal limit of the corpus callosum, the cingulum curves around the
splenium, travelling caudally and laterally to terminate in the parahippocampal
regions. The para-splenial curving cingulate fibers are also known as the isthmus.
The cingulate course is contained within the cingulate gyrus, which lies atop the
corpus callosum. The cingulum is unique in that it is comprised of both long and
short fibers, giving off connections at all points along its longitudinal course
(Fig. 1.2b).
1 The Subcortical Space: Anatomy of Subcortical White Matter 7

a b

c d

Fig. 1.2 (a) Tractography of the limbic white matter tracts. Visible in this left sagittal view are the
cingulum (bright green) and fornix (pink). (b) A medial view of the right hemisphere in a postmor-
tem specimen. The specimen has been transected at the corpus callosum (CC). The cingulum
(Cing.) has been exposed. (c) Further dissection of the medial aspect of the hemisphere reveals the
fornix (For.) and the anterior commissure (AC) . (d) An oblique anterior tractographic view depict-
ing the corpus callosum (dark purple), lying dorsal to the anterior commissure (dark yellow). The
anterior and posterior fibers of the anterior commissure and its distinct handlebar shape are visible
from this view

Fornix and Mammillothalamic Tracts

The fornix is the main efferent limbic pathway. Within the temporal lobe, the fornix
originates from the subiculum and entorhinal cortex as the fimbria travelling pos-
terolaterally as the forniceal crus within each hemisphere. Each crus curves rostrally
around its respective thalamic pulvinar to lie on top of the thalamus, where they join
to form the forniceal body in the midline. The commissural fibers interconnecting
each crus within the body region are known as the psalterium or the hippocampal
commissure. The body continues anteriorly, to the anterior longitudinal extremity of
the thalamus, where it subsequently separates again. Each hemispheric fornix sub-
sequently divides again into anterior and posterior columns, bisected by the anterior
commissure. Anterior fibers primarily terminate within the septal area, the lateral
preoptic area, and the hypothalamus. The posterior columns primarily terminate