• Richard Gonzalo Párraga, LahirishIssa Ali MuftahIAMDepartment of Neurosurgery, Hospital Beneficência Portuguesa, São Paulo - SP, Brazil., Guilherme Carvalhal Ribas, Talita Martins Sarti, da CostaMarcos Devanir SilvaMDSDepartment of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, São Paulo, Brazil., and Feres Chaddad-Neto.
• Director of the Neurosurgery Institute of Bolivia (INEB), Cochabamba, Bolivia.
• World Neurosurg. 2023 Jan 1; 169: e9e15e9-e15.

BackgroundLesions in the ventral striatum region (above the anterior perforated substance) are a challenge for neurosurgeons due to their direct relationship with the lenticulostriate arteries, which difficult the surgical access. The standard approaches for this region include the following: 1) transfrontal approach, 2) transanterior perforating substance approach, 3) transcallosal transventricular approach, and 4) pterional transsylvian-transinsular route. In this study, we aimed to describe a novel anatomical approach through the anterior limiting sulcus of the insula in order to access the ventral striatum.MethodsWe reviewed the literature and performed a detailed dissection of this region by using Klingler's technique with brain specimens injected with silicone, paying special attention to the white fibers and lenticulostriate arteries, and provided a description of an illustrative case of a cavernous malformation.ResultsNeuroanatomical dissections showed that the lenticulostriate arteries had an inverted C-shaped anterior concavity, leaving less significant vascular relationships in the depth of the anterior limiting sulcus of the insula. In the case we described, the cavernous malformation was completely resected and the patient was discharged without any neurological deficits.ConclusionsThe transanterior limiting sulcus of the insula approach to the ventral striatum offers a safe access route for selected cases and can be performed on the basis of anatomical references. Three-dimensional understanding of the intrinsic brain architecture and its relationships with vascular structures in this specific area is important and can be acquired mainly through laboratory training.Copyright © 2022 Elsevier Inc. All rights reserved.

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