An Applied Anatomic Guide to Anterior Temporal Lobectomy and Amygdalohippocampectomy: Laboratory Cranial and White Matter Dissections to Inform Surgical Practice

前颞叶切除术和杏仁核-海马切除术的应用解剖指导：以实验室颅骨和白质解剖熟悉手术实践

METHODS方法

White Matter Dissections

Four normal, adult, cadaveric, formalin-fixed cerebral hemispheres (2 left and 2 right) treated with the Klinger’s technique were studied. The arachnoid membrane and vessels were carefully removed and the specimens were frozen at temperatures between -10 C and -15 C for 2 weeks. They were then allowed to thaw under running water for several hours (freeze-thaw procedure). The fiber microdissection technique was used to reveal the major fiber tracts that travel in or around the actual operative corridor used during the anterior temporal lobectomy, and digital photographs were obtained from every dissection step.

白质解剖

对用Klinger技术处理过的四个正常成人尸体大脑半球（2个左，2个右）进行了研究。仔细地去除蛛网膜和血管，将标本在-10℃至-15℃的温度下冷冻2周。然后让它们在流水下解冻几个小时（冻融程序）。纤维显微解剖技术用于显露前颞叶切除术中走行在实际手术通道内或其周围的主要纤维束，并从每一个解剖步骤中获取数码照片。

Cadaveric dissections

Two formalin-fixed (10% to 15% formalin) and colored-latex–injected cadaveric heads (4 sides) were used. The heads were positioned in a way that resembled the actual operative settings and the pretemporal corridor was used. The intradural procedure was divided into 2 distinct stages. The first stage comprised an “en block” anterolateral temporal neocortical resection sparing the superior temporal gyrus and avoiding entering prematurely the temporal horn. In the next stage, the temporal horn was entered and the resection of the mesial temporal structures along with the amygdala was completed. Microsurgical instruments and the operating microscope (Carl Zeiss OPMI) were used and digital photographs were obtained to vividly illustrate every step (Nikon DSLR D7100, aperture priority mode, ISO sensitivity:100, using flash).

尸体解剖

使用两个经福尔马林固定(10%至15%的福尔马林）并注射彩色乳胶的尸头（4侧）。头部以类似于实际手术设置的方式放置，并使用了颞前通道。硬膜内手术分为两个不同的阶段。第一阶段包括一个“整块”的前外侧颞叶新皮质切除术，保留颞上回并避免过早进入颞角。在下一个阶段，进入颞角并完成内侧颞叶结构和杏仁核切除。使用显微外科器械和手术显微镜（Carl Zeiss OPMI），并获得数码照片来生动地说明每一步（尼康DSLR D7100，光圈优先模式，ISO灵敏度：100，使用闪光灯）。

Illustrative Cases

Four patients (3 males and 1 female, age between 20 and 30 years) underwent a standard right-sided ATL to treat mesial temporal lobe epilepsy. Photographs from distinct intraoperative dissection stages were obtained aiming to pair laboratory findings with their intra-operative equivalent and to offer a consistent and comprehensive anatomic guide for surgical practice. All procedures were performed by the senior author (C.K.).

说明性病例

4名患者（3名男性和1名女性，年龄在20至30岁之间）接受了标准的右侧ATL治疗颞叶内侧癫痫。获得不同术中分离阶段的照片，旨在将实验室结果与术中对应物结果相配对，并为手术实践提供一致且全面的解剖指导。所有手术均由资深作者(C.K.)执行。

IRB/Ethics Committee Approval

IRB/ethics committee approval was not required, because the study was based on cadaveric dissections. Informed consent was obtained from all participants included in the study.

伦理委员会/伦理委员会批准

不需要IRB/伦理委员会的批准，因为该研究是基于尸体解剖进行。研究中的所有参与者都获得了知情同意。

RESULTS

Evidence from white matter dissections    Upon removing the gray matter and U-fibers of the lateral and basal cerebral surface, we focused our attention on the anterior 5 cm of the temporal lobe. The first group of fibers exposed were those of the superior longitudinal fasciculus (SLF)/arcuate fasciculus complex (AF). At the same dissection plane, the parietotemporal aslant tract became evident at approximately 5 cm from the temporal pole (Figure 1A and 1B). The dissection proceeded by removing the gray matter of the insula, the transverse temporal gyri, and the planum temporale. At this step, the middle longitudinal fasciculus (MdLF) was disclosed, travelling from the temporal pole to the parieto-occipital arcus, along the white matter of the superior temporal gyrus (STG) (Figure 1C). After removing the MdLF, deep to the superior temporal sulcus and at the level of the external capsule, the stem of the inferior fronto-occipital fasciculus (IFOF) was unveiled, blending with the fibers of the sagittal stratum posteriorly and the corona radiata anteriorly.

结果

来自白质解剖的证据 在去除大脑外侧和基底表面的灰质和U型纤维后，我们将注意力集中在颞叶前5cm处。 第一组暴露的纤维是那些上纵束（SLF）/弓状束复合体（AF）的纤维。在同一解剖平面上，顶颞斜束在距颞极约5cm处变得明显（图1A和1B）。逐步解剖并去除岛叶、颞横回和颞平面的灰质。在此步骤中，显露了中纵束（MdLF），沿颞上回（STG）白质从颞极到顶枕弓的（图1C）。去除MdLF后，在颞上沟深处和外囊水平，显露与后方的矢状层纤维和前方的放射冠纤维相混合的下额枕束 (IFOF) 干。

FIGURE 2. Stepwise dissection of the basal surface of a right hemisphere. A, The gray matter and U-fibers of the parahippocampal gyrus have been dissected. The hippocampus sitting on the inferomedial wall of the temporal horn, the inferior bundle of the cingulum, and the ILF forming the inferolateral wall of the temporal horn are illustrated. B, The hippocampus, cingulum, and ILF have been removed. The ependymal layer of the temporal horn and the choroid plexus are disclosed. The optic tract is seen to terminate to the lateral geniculate body of the thalamus. Appreciate the correspondence of the LGB to the inferior choroidal point. C, The ependymal layer has been removed, corpus callosum has been sharply cut, and the fibers forming the so-called Meyer’s loop are seen. These fibers originate from the LGB, make an anterior loop, and extend posteriorly to blend with the sagittal stratum. The amygdala nuclei are seen to reside at the anterosuperior part of the temporal horn. Tapetal fibers are seen to radiate from the splenium of the corpus callosum investing the lateral wall of the atrium and temporal horn.

amyg, amygdala; cc, corpus callosum; Ci, cingulum (inferior bundle); cp, choroid plexus; Ep, ependyma; hip, hippocampus; ILF, inferior longitudinal fasciculus; LGB, lateral geniculate body; ML, Meyer’s loop; oc, optic chiasm; on, optic nerve; ot, optic tract; tap, tapetum.

图 2. 右半球基底面的逐步解剖。 A，已解剖海马旁回的灰质和U型纤维。 图中显示了位于颞角下内侧壁上的海马、扣带回下束和形成颞角下外侧壁的ILF。B，海马、扣带回和ILF已被移除。显露了颞角的室管膜层和脉络丛。视束终止于丘脑的外侧膝状体。领会LGB与下脉络膜点的对应关系。C，室管膜层已被去除，胼胝体已被锐性切除，并且可以看到形成所谓Meyer袢的纤维。这些纤维起源于LGB，形成前袢，并向后延伸以与矢状层融合。可见杏仁核位于颞角的前上部。可见毯纤维从胼胝体压部放射状发出，覆盖房部的侧壁和颞角。

amyg，杏仁核； cc，胼胝体； Ci，扣带回（下束）； cp，脉络丛； Ep，室管膜； hip，海马； ILF，下纵束； LGB，外侧膝状体； ML，Meyer袢； oc，视交叉； 视神经上； ot，视束； tap，毯。

Ventrally to the IFOF stem, at the level of the external capsule, the uncinate fasciculus (UF) was revealed, connecting in a hook-shape manner the posterior orbitofrontal cortex with the temporal pole and the uncus. Moving basally, the next crucial white matter pathway encountered was the inferior longitudinal fasciculus (ILF), comprising a dorsolateral part, which runs from the anterior temporal lobe to the occipital lobe, and a fusiform part, which resides in the homonymous gyrus. Dissecting between the stem of the IFOF superiorly and the ILF inferiorly leads to the temporal horn. At this point, one can appreciate how the IFOF courses along the roof of the temporal horn, as part of the temporal stem, and how the ILF runs along the lateral wall and the floor of the temporal horn (Figure 1D). Switching to the medial aspect of the hemisphere, the inferior arm of the cingulum is seen to line the medial side of the hippocampus (Figure 2A). The exposure of the hippocampus was enhanced by cutting along the collateral eminence and ILF up until the inferior choroidal point was identified. We resected the hippocampus proper together with the ILF to expose the roof of the temporal horn with the amygdala seen to reside on its anterior part (Figure 2B).We then meticulously dissected the ependymal layer of the roof of the temporal horn and encountered a group of fibers seen to stem from the lateral geniculate body and follow an anterior loop to travel posteriorly and blend with the sagittal stratum. These fibers form the anterior part of the optic radiation also known as the Meyer’s loop (Figure 2C).

在外囊水平IFOF干的腹侧，显露钩束 (UF) ，以钩状的方式将后眶额皮层与颞极和钩回相连接。向基底部移行，遇到下一个关键的白质通路是下纵束（ILF），包括从前颞叶走形至枕叶的背外侧部和位于同名脑回的梭形部。在上方的IFOF干和下方的ILF干之间解剖通向颞角。此时，就可以理解IFOF作为颞干的一部分如何沿着颞角的顶部走形，以及ILF如何沿着颞角外侧壁和底壁走形（图1D）。 切换到半球的内侧面，可以看到扣带回下臂沿海马的内侧面排列（图 2A）。通过切除沿着侧副隆起和ILF向上直到识别下脉络膜点来增强海马的暴露。我们将海马本身连同ILF一起切除，以暴露颞角顶壁，杏仁核位于其前部（图 2B）。然后，我们仔细解剖了颞角顶壁的室管膜层，发现了一组来自外侧膝状体的纤维，随前袢向后走形并与矢状层融合。这些纤维形成视辐射的前部，也被称为Meyer袢（图 2C）。

Hence, the white matter tracts that are inevitably traversed during ATL are the ILF, UF, and the inferior arm of the cingulum during fusiform gyrus and amygdala resection, respectively. At the posterior limit of the resection, the surgeon should be aware of the SLF/AF complex, particularly on the dominant side. The MdLF travels safely in the white matter of the STG, which is left intact during the procedure. Finally, while manipulating the temporal horn, the surgeon should be vigilant of the temporal stem running on its roof. The temporal stem is the white matter located between the inferior periinsular sulcus and the temporal horn, and consists of the extreme capsule, the external capsule-IFOF-UF, and Meyer’s loop in superficial to deep direction.

因此，在ATL过程中不可避免地穿过的白质束分别是梭状回和杏仁核切除过程中的ILF、UF和扣带下臂。 在切除的后界处，外科医生应该注意SLF/AF复合体，特别是在优势侧。MdLF安全走形在STG的白质中，在手术过程中STG保持完整。最后，在处理颞角时，外科医生应警惕走行在其顶壁的颞干。颞干是位于岛周下界沟和颞角之间的白质，由最外囊、外囊-IFOF-UF和自浅至深方向的Meyer袢组成。

FIGURE 3. ATL and AH stepwise dissection A, C, E, and G, on a cadaveric specimen and B, D, F, and H, on a patient. Right-sided approach. Cadaveric photographs are paired with their intraoperative equivalent. A and B, Positioning: the head is turned 45 on the contralateral side, tilted laterally, and markedly extended to place the long axis of the hippocampus along the operator’s line of sight. A question mark incision starting anterior to the tragus, corresponding to the root of the zygoma (**), curving backward up until the mastoid process (m) and ending at the widow’s peak (*), is drawn on the cadaveric specimen and marked with a white dotted line on the real patient. The or, the STL, and the Sylvian fissure are also marked on the cadaveric specimen. The or, the Sylvian fissure, the STS, and the zygoma (zyg)—representing the middle fossa floor—are marked on the real patient. C and D, A low temporal craniotomy up until the superior temporal line has been performed. The inferior frontal gyrus and superior, middle, and inferior temporal gyri are exposed. E and F, A surgical ruler is placed at the temporal tip and over the middle temporal gyrus to mark the posterior extension of the corticotomy. The resection starts from the superior temporal sulcus or just below it to avoid sulcal vessels and involves the middle and inferior temporal gyri and part of the fusiform gyrus. G and H, In the next step, we enter the temporal horn and identify the choroid plexus and the head of the hippocampus.

or, orbital rim; STL, superior temporal line; STS, superior temporal sulcus.

图 3. 尸体标本A、C、E和G与患者B、D、F 和 H上ATL和AH的逐步解剖。右侧入路。 尸体照片与其术中对应物照片配对。A和B，体位：头部向对侧旋转45°，斜向外侧，并明显后伸以使海马长轴沿术者的视线放置。在尸体标本上画一个问号切口，从耳屏前开始，对应于颧骨根部 (**)，向后上弯曲直至乳突 (m)，止于美人尖 (*)，并在真实患者上以一条白色虚线标记。尸体标本上还标记了or、STL和外侧裂。 代表中颅窝底的or、外侧裂、STS和颧骨 (zyg)均标记在真实患者身上。C和D，完成低位颞部开颅术直至颞上线。暴露额下回和颞上、中、下回。E和F，将手术尺放置在颞尖和颞中回上方，以标记皮层切开术的后部延伸。切除从颞上沟或其正下方开始，以避免颞沟间血管，并涉及颞中回、颞下回以及部分梭状回。 G和H，下一步，我们进入颞角并识别脉络丛和海马头。

or，眶缘； STL，颞上线； STS，颞上沟。

FIGURE 4. The midsubtemporal ridge identified on a cadaveric specimen (*). The right temporal lobe is retracted with a brain spatula. The midsubtemporal ridge is a bony prominence on the middle fossa floor. It corresponds to the point between V1 and V2 divisions of the trigeminal nerve. It can be used to indicate the white matter dissection plane during the lateral neocortical resection. It can also be used as a landmark for the localization of the temporal horn on the anteroposterior axis.

图 4. 在尸体标本上识别出颞下中嵴 (*)。 用脑压板牵拉右侧颞叶。颞下中嵴是中颅窝底的骨性突起。它对应于三叉神经V1和V2分支之间的点（原文为：The midsubtemporal ridge exists near the sphenosquamosal suture. It is also located at the midpoint between the V2 and V3.即为V2和V3之间的中点，详见本文末附2）。它可用于外侧新皮层切除时提示白质解剖平面。 它还可以用作颞角在前后轴上定位的标志。

A Stepwise Guide for ATL and AH

Eight discrete and consecutive steps are highlighted to provide a simple but comprehensive guide for a safe and effective anterior temporal lobectomy. Consistent cranial and parenchymal landmarks to navigate the surgeon through the entire procedure are indicated.

ATL和AH的逐步指导

强调了互不相连的八个连续步骤，为安全有效的前颞叶切除术提供简单但全面的指导。表明了一致的颅骨和脑实质标志以引导外科医生完成整个手术。

Positioning

The patient is placed supine with the head above the heart and fixed in a Mayfield three-point fixation system. The head is turned 45 contralaterally, tilted laterally, and markedly extended to place the long axis of the hippocampus at the operator’s line of sight (Figure 3A and 3B).

体位

患者置于仰卧位，头部高于心脏，并用Mayfield三点固定系统固定。头部向对侧旋转45°，斜向外侧，并明显后伸以使海马长轴沿术者的视线放置（图3A和3B）。

Skin Incision

A question mark incision is fashioned starting anterior to the tragus, extending posteriorly behind the ear at the mastoid vertex line and curving anteriorly above the superior temporal line up until the widow’s peak (Figure 3A and 3B). A single myocuta-neous flap is elevated.

皮肤切口

从耳屏前开始做一问号切口，向后延伸到耳后乳突顶点线处，并在颞上线上方向前弯曲，直到美人尖（图3A和3B）。抬起单个肌皮瓣。

Craniotomy

Two burr holes are drilled, one just above the root of the zygoma and the other at the Dandy keyhole point, just posterior to the frontozygomatic suture, and a craniotomy is turned up until the level of the superior temporal line. Having in mind that the root of the zygoma corresponds to the middle fossa floor and the superior temporal line to the inferior frontal sulcus, the outlined craniotomy will expose the inferior frontal gyrus and the superior, middle, and part of the inferior temporal gyri (Figure 3C and 3D).

开颅术

钻两个骨孔，一个位于颧骨根部正上方，另一个位于Dandy关键孔，就在额颧缝后方，然后开颅术一直转至颞上线水平。考虑到颧骨根部对应于中颅窝底，颞上线对应于额下沟，开颅术的轮廓将暴露额下回以及颞上回、颞中回和部分颞下回（图3C和3D）。

Dural Incision

The dura is incised in a U-shaped fashion and is reflected anteriorly with its base at the sphenoid wing (Figure 3C and 3D).

硬脑膜切开

硬脑膜以U形方式切开，其基底在蝶骨翼处向前反折（图3C和3D）。

FIGURE 5. Coronal cuts of a right hemisphere. A, The yellow dotted line indicates the direction of the white matter dissection during the lateral neocortex resection. The dissection starts from the superior temporal gyrus or immediately below it and aims toward the middle fossa floor. As soon as the gray matter of the basal temporal sulci is recognized (yellow star), the surgeon should direct the dissection toward to avoid entering the temporal horn prematurely. B, The lateral neocortex of the temporal lobe has been resected. The yellow arrow indicates the point of entrance into the temporal horn.

hip, hippocampus; ITS, inferior temporal sulcus; OTS, occipitotemporal sulcus; STS, superior temporal sulcus; T1, superior temporal gyrus; T2, middle temporal gyrus; T3, inferior temporal gyrus; T4, fusiform gyrus; T5, parahippocampal gyrus; TS, temporal stem.

图 5. 右侧大脑半球的冠状切面。 A，黄色虚线表示外侧新皮层切除过程中白质解剖的方向。解剖从颞上回或其正下方开始，瞄准中颅窝底。一旦识别出颞基底沟的灰质（黄色星），外科医生应朝向它对准解剖方向以避免过早进入颞角。 B，已切除颞叶外侧新皮层。黄色箭表示颞角入口点。

hip，海马； ITS，颞下沟； OTS，枕颞沟； STS，颞上沟； T1，颞上回； T2，颞中回； T3，颞下回； T4，梭状回； T5，海马旁回； TS，颞干。

Anterolateral Temporal Lobectomy

Anterolateral temporal lobectomy involves the anterior 3.5 to 4 cm of the nondominant and the 3 to 3.5 cm of the dominant temporal lobe, always sparing the superior temporal gyrus. A Penfield dissector is placed at the temporal tip, over the middle temporal gyrus, to mark the posterior extension of the corticotomy (Figure 3E and 3F). A constant bony landmark on the middle fossa floor, the midsubtemporal ridge,
coincides also with the posterior limit of the resection (Figure 4). White matter dissection begins just below the superior temporal sulcus to avoid sulcal vessels. The dissection is carried for 2 to 3 cm deep down to the middle fossa floor and involves the middle temporal, inferior temporal, and part of the fusiform gyri. It is advised not to enter the temporal horn prematurely because intraventricular anatomy could be distorted from the ingress of blood. The gray matter of the occipitotemporal sulcus is a sound parenchymal landmark that navigates the surgeon and limits the medial dissection up to the fusiform gyrus. Once this gray matter is identified, the dissection plane should be directed inferiorly toward it to avoid hitting the temporal horn (Figure 5).

前外侧颞叶切除术

前外侧颞叶切除术涉及非优势颞叶前部3.5-4cm和优势颞叶前部3-3.5cm，始终保留颞上回。将Penfield解剖器放置在颞中回上方的颞尖处，以标记皮层切开术的后部延伸（图3E和3F）。中颅窝底上的一恒定骨性标志，即颞下中嵴，也与切除的后界重合（图4）。从颞上沟下方开始白质解剖，以避免沟间血管。解剖深度为2-3cm，直至中颅窝底，涉及颞中回、颞下回和部分梭状回。建议不要过早进入颞角，因为血液的进入可能会扭曲脑室内的解剖结构。枕颞沟的灰质是一个可靠的脑实质标志，可以引导外科医生并将内侧解剖限制在梭状回。一旦识别出该灰质，解剖平面应向下对准它，以避免碰到颞角（图5）。

Entering the Temporal Horn

Upon completing the lateral neocortical resection, the microscope is tilted medially. The temporal horn is located deep at the level of the middle temporal gyrus, approximately 3 cm posterior to the temporal tip. Novice surgeons can miss the temporal horn by searching for it too anteriorly or superiorly and therefore risking injury to the temporal stem, insula, or middle cerebral artery (MCA). To avoid disorientation, the importance of identifying and following the gray matter of the basal temporal sulci is again highlighted. Entry into the temporal horn is confirmed by the release of cerebrospinal fluid and identification of the choroid plexus (Figure 3G and 3H).

进入颞角

完成外侧新皮层切除后，显微镜向内侧倾斜。颞角位于颞中回水平深处，距颞尖后方约3cm。外科医生新手可能会因过于靠前或靠上方寻找而错过颞角，因此存在损伤颞干、岛叶或大脑中动脉(MCA)的风险。为了避免迷失方向，再次强调识别颞基底沟灰质并循着它的重要性。通过释放脑脊液和识别脉络丛来确认进入颞角（图3G和3H）。

Hippocampal Resection

Once the temporal horn is entered, the superior temporal gyrus is retracted with a fixed brain spatula to elevate gently the roof of the temporal horn and allow better visualization and surgical manipulation of the mesial temporal structures. The inferior choroidal point that demarcates the hippocampal head from the body is identified, and the disconnection of the hippocampal body lateral to the choroid plexus can be initiated. The dissection proceeds aiming to resect “en block” the hippocampal head, the posterior uncus, the parahippocampal gyrus, and the remaining part of the fusiform gyrus. The dissection is initiated with the bipolar cautery and the suction device, but as the surgeon proceeds medially, an ultrasonic aspirator and/or a microdissector can be used to gently resect these structures from their pia cover, which should be kept intact to act as a protective veil for the contents of the basal cisterns. The tentorial edge, the oculomotor nerve, the P2 segment of the posterior cerebral artery, the anterior choroidal artery, the basal vein, and the optic tract can be appreciated subpially in a ventrodorsal direction (Figure 6).

海马切除术

一进入颞角，就用一固定的脑压板牵拉颞上回以轻轻抬起颞角顶壁，以便更好地对内侧颞叶结构进行可视化和手术操作。识别将海马头与体分开的下脉络膜点，并且可以开始断开脉络丛外侧的海马体。解剖的目的是“整块”切除海马头、钩回后部、海马旁回和梭状回的其余部分。用双极电凝和吸引装置开始解剖，但当外科医生向内侧推进时，可以使用超声吸引器和/或显微剥离子轻轻地从软脑膜覆盖物上切除这些结构，软脑膜覆盖物应保持完整以充当基底池内容物的保护罩。在腹背侧方向可见到软膜下的小脑幕缘、动眼神经、大脑后动脉P2段、脉络膜前动脉、基底静脉和视束（图6）。

FIGURE 6. Final view of a right anterior temporal lobectomy and amygdalohippocampectomy A, on a cadaveric specimen and B, on a patient. Upon completion of the amygdalohippocampectomy, one can appreciate the basal cistern contents through their arachnoid membrane. The tentorial edge lines the inferolateral margin of the resection area. The oculomotor nerve, the P2 segment of the posterior cerebral artery, the anterior choroidal artery, the basal vein, and the deep sylvian vein can be appreciated subpially in B. A, In the cadaveric specimen, the arachnoid membrane is removed to provide a more accurate view of the above-mentioned neurovascular structures.

Ant. Ch., anterior choroidal artery; basal v., basal vein; cn III, cranial nerve III; Deep Sylv. v., deep Sylvian vein; M1, proximal segment of MCA; MCA, middle cerebral artery; ot, optic tract; PCA, posterior cerebral artery; PCOM, posterior communicating artery.

图6. 右前颞叶切除术和杏仁核-海马切除术的A（尸体标本）和 B（患者）最终视图。杏仁核-海马切除术完成后，就可以通过蛛网膜见到基底池的内容物。小脑幕缘排列在切除区域的下外侧缘。动眼神经、大脑后动脉P2段、脉络膜前动脉、基底静脉和侧裂深静脉可以在B的软膜下观察到。A，在尸体标本中，去除蛛网膜以提供上述神经血管结构的更准确地视图。

Ant.Ch.，脉络膜前动脉； basal v.，基底静脉； cn III，动眼神经；Deep Sylv. v.，侧裂深静脉； M1，MCA近端； MCA，大脑中动脉； ot，视束； PCA，大脑后动脉； PCOM，后交通动脉。

Amygdala Resection

The amygdalar nuclei correspond to the anterior uncus. Interestingly, there is no landmark to differentiate the amygdala from the globus pallidus and basal ganglia, and therefore, their safe resection is risky (Figure 7). It has been proposed that the imaginary line connecting the MCA near the limen insulae to the anterior choroidal point can act as an effective dorsal intraoperative limit for the amygdala resection. If the MCA has not been already identified, removing the white matter of the medial part of the STG should suffice to recognize the artery. Alternatively, the surgeon can identify the posterior communicating artery through the basal arachnoid and follow it all the way up to the internal carotid artery and MCA (Figure 6).

杏仁核切除术

杏仁核对应于钩回前部。有趣的是，没有区分杏仁核与苍白球和基底神经节的标志，因此，它们的安全切除是有风险的（图7）。有人提出，连接岛阈附近的MCA到前脉络膜点的假想线可以作为杏仁核切除术中有效的背侧界。如果MCA尚未被识别，去除STG内侧部分的白质就足以识别该动脉。或者，外科医生可以通过基底的蛛网膜识别后交通动脉，并循着它一直到颈内动脉和MCA（图6）。

FIGURE 7. Coronal cut of a left hemisphere. The proximity of the amygdala to the basal ganglia is vividly illustrated. *Middle cerebral artery M2 branches.

ac, anterior commissure; amyg, amygdala; cc, corpus callosum; cl, claustrum; cn, caudate nucleus; ec, external capsule; exc, extreme capsule; gp, globus pallidus; hip, hippocampus; ic, internal capsule; ins, insula; ips, inferior periinsular sulcus; on, optic nerve; put, putamen; sps, superior peri-insular sulcus; th, temporal horn; TS, temporal stem.

图7。左侧大脑半球的冠状切面。生动地说明了杏仁核与基底神经节的接近程度。*大脑中动脉M2分支。

ac，前连合；amig，杏仁核；cc，胼胝体；cl，屏状核；cn，尾状核；ec，外囊；exc，最外囊；gp，苍白球；hip，海马；ic，内囊；ins，脑岛；ips，岛下界沟；on，视神经；put，壳核；sps，岛上界沟；th，颞角；TS，颞干。

FIGURE 8. Projection of the related white matter fiber tracts on an intraoperative image of a right anterior temporal lobectomy.

AF, arcuate fasciculus; cp, choroid plexus; hip, hippocampus; IFOF, inferior frontooccipital fasciculus; ILF, inferior longitudinal fasciculus; SLF, superior longitudinal fasciculus; STG, superior temporal gyrus; UF, uncinate fasciculus.

图 8. 右前颞叶切除术术中相关白质纤维束的投影图像。

AF，弓状束； cp，脉络丛； hip，海马； IFOF，下额枕束； ILF，下纵束； SLF，上纵束； STG，颞上回； UF，钩束。