Insular gliomas represent a unique surgical challenge due to the complex anatomy and nearby vascular elements associated within the Sylvian fissure. For certain tumors, the transsylvian approach provides an effective technique for achieving maximal safe resection.
Transsylvian approaches shorten the surgical distance to these lesions, preserve perisylvian temporal and frontal cortex, and minimize brain transgression.
The anterior approach opened the sphenoidal and insular portions of the sylvian fissure and exposed the limen insulae and short gyri of insula, whereas the posterior approach opened the insular and opercular portions of the sylvian fissure and exposed the circular sulcus and long gyri.
The transsylvian approach 1) through a pterional craniotomy 2) 3) is particularly useful for anterior basal extrinsic lesions and for frontobasal, mesial temporal, and insular intrinsic intracranial lesions.
Transsylvian-transinsular approaches safely expose vascular pathology in or deep to the insula while preserving overlying eloquent cortex in the frontal and temporal lobes. The anterior transsylvian-transinsular approach can be differentiated from the posterior approach based on technical differences in splitting the sylvian fissure and anatomic differences in final exposure. Discriminating patient selection and careful microsurgical technique are essential 4).
A transsylvian anteromedial approach through the pyriform cortex at the level of the anterior and superior surface of the uncus enables a safe entry into the temporal horn without injury to the optic radiation fibers or the main part of the uncinate fasciculus 5).