Fig. 15.3). The first step in splitting the sylvian fissure is to dissect beyond the veins. In general, superficial sylvian veins are mobilized to the temporal side of the fissure because they course inferiorly and bridge to the sphenoparietal sinus under the sphenoid ridge. Dissection along the temporal side of the veins would ultimately cross their outflow connections, whereas dissection along the frontal side can preserve these connections.
Fig. 15.2 Normal variations of middle cerebral artery anatomy. (A) MCA bifurcation, equal trunks. (B) MCA bifurcation, inferior trunk dominant. (C) MCA bifurcation, superior trunk dominant. (D) MCA trifurcation. (E) MCA quadrifurcation. (F) Duplicated M1 MCA segment. (G) Accessory M1 MCA segment. Anterior branches include the orbitofrontal artery, operculofrontal artery, and central sulcus artery; posterior branches include the posterior parietal artery, angular artery, and posterior temporal arteries. A–P, anteroposterior; MT, middle trunk; MTi, middle trunk, inferior, MTs, middle trunk, superior; RAH, recurrent artery of Heubner.
Cortical arachnoid is incised with the tip of an up-facing No. 11 scalpel blade, lifting this layer off the underlying veins and nicking it. One blade of a short microscissors enters the subarachnoid space through that nick and continues the incision, again lifting the arachnoid with the scissors blade to clear the underlying veins. Arachnoid is incised along the superficial sylvian vein from distal to proximal, coagulating and cutting venous tributaries from the frontal lobe (
Fig. 15.4, step 1). The superficial sylvian vein is gradually detached from the frontal lobe and mobilized temporally (
Fig. 15.4, step 2).
Fig. 15.5). An anterior sylvian venous system drains to the sphenoparietal sinus, cavernous sinus, and sphenobasal or sphenopetrosal sinuses; a posterior sylvian venous system drains to the lateral temporal veins, vein of Labbé, and transverse sinus; and a superior sylvian venous system drains to the frontoparietal veins, vein of Trolard, and the superior sagittal sinus (SSS). Convergence of these three venous systems along the sylvian fissure can create an obstructive tangle of veins, but it also establishes collateral venous connections that allow patients to tolerate sacrifice of a vein. Most of the time, a large sylvian vein can be rolled away from the frontal lobe and preserved. Sometimes the plane between paired sylvian veins may be the easiest pathway into the fissure. Occasionally, an adherent vein does not mobilize temporally and may need to be divided, provided that the dominant sylvian trunk is preserved and that it connects with other venous systems. Veins should be protected, but opening the sylvian fissure can require some venous pruning. The rarity of venous complications after splitting the sylvian fissure attests to the interconnections between the sylvian venous systems. Venous sacrifice can increase venous pressure in the sylvian veins and increase their fragility, so it should be delayed until the sylvian fissure split is further along.
As dissection along the superficial sylvian vein reaches the temporal pole, cortical arachnoid of the distal sylvian cistern transitions to sphenoidal arachnoid of the proximal sylvian cistern. From the surgeon’s perspective, this sphenoidal arach noid is vertically oriented, and cortical arachnoid is horizontally oriented (
Fig. 15.6). Sphenoidal arachnoid should be opened before proceeding to deep sylvian dissection because it couples the frontal and temporal lobes and resists deep spreading dissection. The steep view down this plane may require some frontal retraction with swollen brains. The sylvian veins frequently lie beneath sphenoidal arachnoid or can penetrate it en route to the sphenoparietal sinus. Subarachnoid hemorrhage can hide these veins, but lifting dissection with the microscissors protects underlying veins.
Fig. 15.7, step 3). Superficial sylvian dissection along the veins aligns the microscope at a shallow angle, whereas deep sylvian dissection along the opercular segments of the MCA branches aligns the microscope at a steep, downward angle, almost back toward the neurosurgeon. Cutting arachnoid bands between the frontal and temporal lobes initiates this dissection. The working area around an artery should be widened circumferentially like a funnel, rather than like a cylinder, to avoid constricted corridors. Similar working areas around adjacent opercular arteries can be developed and connected to neighboring areas of dissection (
Fig. 15.7, step 3).
Small opercular arteries lead to larger insular arteries, and insular arteries lead to the trunks of the MCA bi- or trifurcation (
Fig. 15.7, step 4). The dissection becomes easier as it deepens because insular arteries widely separate the frontal and temporal lobes. Spreading dissection along the arteries parts the lobes from “inside out,” following a wide plane of separation deep in the sylvian fissure to narrow, more adherent areas superficially. Yasargil analogized this dissection to splitting an orange, where radial force directed outward from the center easily separates the orange wedges. The sylvian fissure is often most adherent superficially near the pterion where there are few arteries between the frontal and temporal lobes to separate the lobes. Lobules can even interdigitate, adding a rolling contour to this plane of contact (
Fig. 15.8, frontal-herniating or temporal-herniating fissures). Spreading dissection from inside out is the best method for opening these difficult tissue planes. When tissues still do not separate easily, an artery might be found under sphenoidal arachnoid in the proximal fissure to reestablish the subarachnoid plane.
