The variations of sylvian veins and cisterns in anterior circulation aneurysms

Summary

The anatomical variations of Sylvian vein and cistern were investigated during the pterional approach in 230 patients with 276 aneurysms of anterior circulation arteries, that were operated on at the Neurosurgical Department of Atatürk University Medical School, Erzurum, Turkiye. All patients underwent radical surgery for aneurysm by the right or left pterional approach. The findings were recorded during surgical intervention and observed through the slides and videotapes of the operations.

In our study, we surgically classified the variations of the Sylvian vein, according to its branching and draining patterns. Type I: The fronto-orbital (frontosylvian), fronto-parietal (parietosylvian) and anterior temporal (temporosylvian) veins drain into one sylvian vein. Type II: Two superficial Sylvian veins with separated basal vein draining into the sphenoparietal and Rosenthal's basal vein. Type III: Two superficial Sylvian veins draining into the sphenoparietal and the superior petrosal veins. Type IV: Hypoplastic superficial Sylvian vein and the deep one. Four types of Sylvian vein variations were defined as follows. The Type I was seen in 45% (n = 103), the Type II was found in 29% (n = 67), Type III was recorded in 15% (n = 34) and Type IV, or hypoplastic and deep form was discovered in 11% (n = 26) of patients. The course of the Sylvian vein was on the temporal side (Temporal Coursing) in 70 percent of the cases (n= 160), on the frontal side (Frontal Coursing) in 19% of the patients (n = 45) and in 8 percent of the cases (n= 18) in the deep localization (Deep Coursing). Only 3 percent of the cases (n = 7) showed a mixed course. The variations of the Sylvian cisterns were classified into three types, according to the relationships between the lateral fronto-orbital gyrus and the superior temporal gyrus. In Sylvian Type, the frontal and temporal lobes are loosely (Sylvian Type A, Large) or tightly (Sylvian Type B, Close and Narrow) approximated on the surface thereby covering the area of the Sylvian cistern. In frontal type, the proximal part of the lateral fronto-orbital gyrus herniated into the temporal lobe. In temporal type, the proximal part of the superior temporal gyrus herniated into the lateral fronto-orbital gyrus. The variations of the Sylvian cisterns in 230 patients were as follows: in 31% (n = 71) Sylvian Type A, in 21% (n = 48) Sylvian Type B, in 34% (n = 78) Frontal Type, and in 14% (n = 33) Temporal Type.

We concluded that venous perfusion disorder of the brain is the most important factor during the pterional approach. Careful intraoperative assessment and protection of the Sylvian vein, which is a surgical pitfall, is an indispensable part of the operation. The recognition of the anatomical variations of the Sylvian vein and cistern, and the detailed knowledge of the microvascular relationships at that level will allow the neurosurgeon to construct a better and safter microdissection plan, to save time and can prevent postoperative neurological deficits.