A description of cerebral veins under operative versely, where there are large arterial vessel stems (at the base of the brain) the veins somewhat lose their technical aspects is practically a description of opera significance. They become important again in the tive approaches and their obstruction by cerebral region of the basal Dura, the Tentorium, and the Falx veins. It is this which constitutes the major difference but (with the exception of the region of the Sinus between arteries and veins. The arteries of the brain originate from only four large vessel stems, which cavernosus) away from the large arterial stems. This justifies writing a microneurosurgical textbook exclu bridge the CSF space and then run along the surface sively under the aspect of the cerebral veins. of the brain or inside the brain. Arterial vessels hardly interfere with operative approaches, even in the deep That we know so much about cerebral veins is due CSF spaces such as the Sylvian fissure, the Tentorium primarily to the work of neuroradiologists. It is not fissure, and the ventricle system. Veins, on the other the objective of the present volume to provide a hand, can appear in almost every location of the brain compreherisive and comparative survey of the large as so-called bridging veins. They are extremely vari number of individual results of attempts at establish able and can bloc~ the approach to deep CSF spaces ing vein types.

Preface In the present volume various approaches to the same in relation to the surrounding brain structures and target area in the deep regions of the brain are cerebral vessels. Here it is to be noted that the so described. In the previous volumes this aspect was called "quadrigeminal" region consists not only of the taken little into account. The author endeavored to Cisterna tecti, but the nearby fissures (Fissura trans describe particularly the typical operative approaches versa cerebri and Fissura horizontalis cere belli) and their principles to make it easier for the beginner should also be included. The pathological processes to learn the microsurgical techniques in interventions do not generally confine themselves to the Cisterna in the central nervous system. tecti, but extend over the neighboring fissures. The Now problematical processes in the immediate vicini Cisterna tecti extends without limits into the neigh ty of the brainstem area have been exclusively boring fissures and into the Cisterna ambiens. selected. They have been separated into dorsal, later As previously, besides personal operational experi ences (which are not marked as such) also interven al and ventral processes with locations mainly in the dorsal, lateral or ventral cisternal areas. Each of tions are presented which have been carried out by these three groups has been separated again into co-workers.

Preface Drawings and scripts were selected from those tion of the operative routes and their alternatives which were produced by the author in the last for well-defined anatomical target areas alone. This three years to help educate young neurosurgeons viewpoint becomes more and more important, be in Freiburg and in other clinics. cause today there is no anatomical structure of the This programm for education may be managed in 2 brain which cannot be approached with a minimal steps: risk for surviving the operation. But more and more - Learning techniques for performing of trepana the risk for neurologicalor psychological postopera tions from opening of the skin onto dura incision tive complications will rise if the anatomical and (step 1) neurophysiological knowledge is insufficient. These - Learning of techniques for routine operations viewpoints are most important in operations at the (e. g. , for extirpation of gliomas of cerebral lobes) cranial base and operations transcrossing midline (step 2) structures of the brain. An intensive anatomical - Learning of techniques for operative approach es training helps to understand MRI before opera in problematic areas of the cranial and cerebral tion. Often the modern MRI demonstrates more base and of the midline, especially for the often anatomical details than the unexperienced neurosur performed operations, e. g. for basal meningeo geon has understood.

In the previous volume, "Differential Approaches in - if approach is hindered through such variants, or - if the lesion itself has a close relationship to impor- Microsurgery of the Brain", the particularly prob lematical operations in the depth of the brain around tant vessels, for example, if arteries penetrate or the brainstem were covered. Even more than in other are just adjacent to a meningioma. operations on the brain, it was important here to decide before the operation which from several pos On the basis of this method, it was obvious to first sible approaches would be chosen. Therefore in this present the description of the veins and then to con present volume, it was obvious to try to describe sider the arteries and not to choose the direction of microsurgical operations of the brain primarily under the blood flow in the image analysis, as is usually the aspect of preoperative planning. This is done by done. Only then can one judge which problems might presenting the usual daily preliminary discussions be encountered. Certainly only a part of the suspected which have taken place in the Freiburg Clinic for the problems will show up during the operation. How last ten years. On the day before surgery, these ever, in view of the great number of possible difficul discussions are always carried out according to the ties, one should also be prepared for rare complica same principle: tions.

Preoperative Magnetic Resonance Imaging allows now a better analysis of the relationship between intracranial tumors and the surrounding brain tissue. Even very small deepseated tumors can be identified during the operation by intraoperative ultrasound. These technological advances have had a great influence on indications, planning strategies and microsurgical techniques. The author shows the functional anatomy of the brain with the eye and the mind of a microsurgeon and demonstrates well known topographical relationships under the aspect of an utmost gentle operative approach.

This book is a sequel to my "Atlas of Topographi sor A.L. Rhoton, Professor K. Sugita and particu larly Professor M.G. Ya{sect}argil (with operation dem cal Anatomy of the Brain and Surrounding Struc tures". Like the first volume it is addressed mainly onstrations in Ziirich), as well as recent descrip to neurosurgeons, neurologists and neuro tions of operations, provided important stimuli. The pathologists. Although the two books deal with dif conversations held with my colleagues were also important for the production of this Atlas. I am par ferent aspects of the subject, that is, the first with anatomical relationships and the present work with ticularly grateful to Dr. J. Gilsbach, Dr. H.-R. Eg neurosurgical techniques, this book will also be of gert and Dr. E. Grobner for valuable suggestions. Special thanks are also due to Doz. Dr. Ch. Oster interest not only to the neurosurgeons but to work ers in allied fields as well. The book has been tag for his help with the evaluation of the computer designed to give the neuroradiologist and tomograms. Professor F. Mundinger provided com neuropathologist a closer insight into the mor puter tomograms from his Department (Stereotaxy and Nuclear Medicine). Thanks to my collaboration phological problems facing the neurosurgeon work with Dr. H.-H. Riemschneider, Specialist for ing under high magnification, and to assist them in Radiology, Karlsruhe, from whom I obtained several making an accurate diagnosis and in determining computer tomograms.

Preface matic depiction of the NMR slices in three levels. The Supported by NMR it has become possible to carry out operations in socalled inoperable regions of basal book is completed with selected technical tricks in ganglia, brainstem and problematic areas of the cor problematic operation cases. tex as well as in the areas of limbic system. Special appreciation is due to Prof. Dr. B. Volk, Thus the planning of an operation has become widely Director of the Institute of Neuropathology of the extended. A widening of the knowledge of the ana University of Freiburg, for his advice and help. tomical fundamentals is therefore indispensable and For nearly all MRI-findings I have to thank the should be conveyed by means of this book. colleagues of the Institute of Radiology (Director: The last two volumes "Anatomical Dissections for Prof. Dr. W. Wenz), especially Dr. Dorothea Ott, Use in Neurosurgery Vol. 1 and 2" supply the mor Dr. T. Adam and Dr. B. Wimmer. I also have to phological base for this book. The book itself is a thank Dr. R. Fiirmaier (neuroradiologist in Freiburg) continuation of "Planning Strategies of Intracranial for several MRI- and CT-findings. Microsurgery" . Most of the CTs were made in the stereotactic depart Some very problematic operations were carried out ment (Director: Prof. Dr. F. Mundinger) of our cli by my co-worker, Priv.-Doz. Dr. Eggert, who is now nic. I want to thank in particular Dr. M. Mohadjer.

The differentiation of the temporal lobe into a lateral neocortical and a medial allocortical region is supported by developmental, anatomical and clinical evidence. Although this view of a dual temporal lobe is generally accepted by neurosurgeons dealing with functional surgery, it still receives little attention by those approaching structural abnormalities located or extending into the medio-basal region. Consequently, the characterization of the temporo-medial area as a distinct surgical region is still lacking. The major object of this study is to analyse the medial part of the temporal lobe as a distinct surgical region and to integrate the microsurgical and physiological aspects into a concept applicable to the several types of temporo-medial lesion. The study includes five sections. The first section is devoted to the morphological aspects; the second and the third sections present a simplified clinical approach to temporo-medial lesions and analyse the ancillary investigations which are indispensable for characterizing their structural and functional features. The fourth section deals with the surgical aspects of temporo-medial lesions, and especially with the selection of the optimal approach in regard to the location of a given process, and to the extent of the functional changes. The last section is devoted to commentaries concerning the neuropathological aspects and the outcome of surgery in the temporo-medial region.

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