De Benedictis Alessandro, Duffau Hugues, Paradiso Beatrice, Grandi Enrico, Balbi Sergio, Granieri Enrico, Colarusso Enzo, Chioffi Franco, Marras Carlo Efisio, Sarubbo Silvio
Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Roma, Italy.
J Anat. 2014 Aug;225(2):132-51. doi: 10.1111/joa.12204. Epub 2014 Jun 30.
The temporo-parieto-occipital (TPO) junction is a complex brain territory heavily involved in several high-level neurological functions, such as language, visuo-spatial recognition, writing, reading, symbol processing, calculation, self-processing, working memory, musical memory, and face and object recognition. Recent studies indicate that this area is covered by a thick network of white matter (WM) connections, which provide efficient and multimodal integration of information between both local and distant cortical nodes. It is important for neurosurgeons to have good knowledge of the three-dimensional subcortical organisation of this highly connected region to minimise post-operative permanent deficits. The aim of this dissection study was to highlight the subcortical functional anatomy from a topographical surgical perspective. Eight human hemispheres (four left, four right) obtained from four human cadavers were dissected according to Klingler's technique. Proceeding latero-medially, the authors describe the anatomical courses of and the relationships between the main pathways crossing the TPO. The results obtained from dissection were first integrated with diffusion tensor imaging reconstructions and subsequently with functional data obtained from three surgical cases, all resection of infiltrating glial tumours using direct electrical mapping in awake patients. The subcortical limits for performing safe lesionectomies within the TPO region are as follows: within the parietal region, the anterior horizontal part of the superior longitudinal fasciculus and, more deeply, the arcuate fasciculus; dorsally, the vertical projective thalamo-cortical fibres. For lesions located within the temporal and occipital lobes, the resection should be tailored according to the orientation of the horizontal associative pathways (the inferior fronto-occipital fascicle, inferior longitudinal fascicle and optic radiation). The relationships between the WM tracts and the ventricle system were also examined. These results indicate that a detailed anatomo-functional awareness of the WM architecture within the TPO area is mandatory when approaching intrinsic brain lesions to optimise surgical results and to minimise post-operative morbidity.
颞顶枕（TPO）交界区是一个复杂的脑区，深度参与多种高级神经功能，如语言、视觉空间识别、书写、阅读、符号处理、计算、自我认知、工作记忆、音乐记忆以及面部和物体识别。最近的研究表明，该区域被厚厚的白质（WM）连接网络所覆盖，这些连接在局部和远距离皮质节点之间提供了高效的多模态信息整合。对于神经外科医生来说，充分了解这个高度连接区域的三维皮质下结构，以尽量减少术后永久性神经功能缺损，非常重要。本解剖学研究的目的是从手术地形学角度突出皮质下功能解剖结构。按照克林格勒技术对取自四具人类尸体的八个大脑半球（四个左侧，四个右侧）进行了解剖。作者从外侧向内侧依次描述了穿过TPO的主要神经通路的解剖走行及其相互关系。解剖结果首先与扩散张量成像重建结果相结合，随后与从三个手术病例获得的功能数据相结合，这三个病例均为清醒患者中使用直接电刺激定位技术切除浸润性胶质肿瘤。在TPO区域内进行安全病变切除术的皮质下界限如下：在顶叶区域，为上纵束的前水平部，更深层为弓状束；在背侧，为丘脑皮质垂直投射纤维。对于位于颞叶和枕叶的病变，应根据水平联合通路（额枕下束、下纵束和视辐射）的走行进行个体化切除。还研究了白质束与脑室系统之间的关系。这些结果表明，在处理脑内原发性病变时，必须对TPO区域内的白质结构有详细的解剖功能认识，以优化手术效果并减少术后并发症。
