ANATOMIC REPORT

Microsurgical Anatomic Features of the Lamina Terminalis

Oreste de Divitiis, M.D., Filippo Flavio Angileri, M.D.,

Domenico d’Avella, M.D., Manfred Tschabitscher, M.D.,
Francesco Tomasello, M.D.
Neurosurgical Clinic (OdD, FFA, Dd’A, FT), University of Messina Medical School,
Messina, Italy, and Department of Anatomy I (MT), University of Vienna,
Vienna, Austria

OBJECTIVE: The lamina terminalis (LT) is a structure of considerable interest for microneurosurgery, and precise
knowledge regarding its normal anatomic features and the variations thereof is required. The purpose of this
study, which was based on microanatomic dissection of human cadaveric specimens, was to review the
microsurgical anatomic features of the LT and its neurovascular relationships. The surgical implications of the
morphometric data are discussed.
METHODS: The region of the LT was examined in 10 human cadaveric heads, obtained from 8 fresh adult cadavers
and 2 formalin-fixed adult cadavers, and in 10 formalin-fixed, isolated, adult brains. An operating microscope was
used for all dissections and measurements.
RESULTS: Assuming the LT to be a triangular structure, we performed measurements of the distance between the
midportion of the upper edge of the chiasm and the lower edge of the anterior commissure (height), which averaged
8.25 mm. The distance between the medial edges of the optic tracts (base) averaged 12.81 mm. The area averaged
52.84 mm2. A minimal amount of retraction was needed to fully expose the LT, and generally there was no need to
mobilize the anterior cerebral artery-anterior communicating artery complex. Perforating branches to the hypothal-
amus and optic apparatus are laterally located and do not interfere with LT incision and/or fenestration.
CONCLUSION: The LT constitutes a clearly identifiable microsurgical target. The allowable extent of LT opening is
sufficient to provide wide access into and free cerebrospinal fluid flow from the third ventricle. Fenestration of
the LT is a safe procedure, provided that the relevant anatomic landmarks are identified and respected.
(Neurosurgery 50:563–570, 2002)
Key words: Anterior communicating artery, Lamina terminalis, Microsurgical anatomy, Perforating branches, Pterional approach

A
t the base and front of the brain, a transparent whitish
membrane, the lamina terminalis (LT), forms most of the
anterior wall of the third ventricle. The LT, which is
composed of a thin sheet of gray matter covered by a pial layer
(9), is of considerable microneurosurgical interest. Lesions that
occur within the anterior third ventricle or invade or compress
the walls of the chamber, including a wide range of pathological
entities (1), can be reached via different surgical approaches with
incision of the LT. Additional interest in this structure is based
on recent observations indicating a role for LT fenestration
among patients with aneurysmal subarachnoid hemorrhage,
with respect to post-subarachnoid hemorrhage hydrocephalus
and vasospasm prevention (12, 14, 15, 19).
The area in and around the anterior third ventricle is dense
with vital anatomic structures. The LT itself involves impor-
tant vascular and neural relationships. Since the original de-
scription by Retzius (8) in the previous century, only a few
reports, which only partially addressed LT anatomic features,
have been published (4, 5, 16). In those articles, not all of the
microanatomic data required by modern microneurosurgery
for navigation within this limited but critical area can be
found. The purpose of this article, which is based on micro-
anatomic dissections of human cadaveric specimens, is to
describe the microsurgical anatomic features of the LT and its
neural and vascular relationships. The surgical implications of
the morphometric data are discussed.
MATERIALS AND METHODS
The region of the LT was examined in 10 human cadaveric
heads, obtained from 8 fresh adult cadavers and 2 formalin-
fixed adult cadavers, and in 10 formalin-fixed, isolated, adult

Neurosurgery, Vol. 50, No. 3, March 2002 563

564 de Divitiis et al.

brains. In cadaveric head specimens, the arterial and venous

systems were injected, under pressure, with colored silicone
rubber (Dow Corning, Midland, MI) via the internal carotid
arteries and internal jugular veins, respectively. An operating
microscope (Carl Zeiss Co., Oberkochen, Germany) set at a
magnification of ⫻6 to ⫻40 was used for all dissections and
measurements.
The cadaveric head specimens were positioned in the usual
manner for right pterional or bilateral subfrontal approaches.
In six cases, a standard pterional craniotomy was performed,
with flattening of the lateral sphenoid ridge and opening of
the sylvian fissure. The ipsilateral optic nerve and internal
carotid artery were exposed. The carotid, chiasmatic, interpe-
duncular, LT, and basal sylvian cisterns were entered and
dissected. A self-retraining retractor was adjusted parallel to
the anterior communicating artery (AComA), to fully expose
the LT (Fig. 1). The degree of retraction applied was based on FIGURE 2. Cadaver photograph. In this fresh cadaveric head
our previous surgical experience regarding the retraction that specimen, a bifrontal craniotomy extending to the level of
is possible without causing injury to neural or vascular struc- the frontal base was performed. The frontal lobes were
tures, taking into account the decreased tissue compliance of retracted so that the LT was fully exposed. Both optic nerves,
cadaveric brain tissue. In four cases, a bifrontal craniotomy the optic chiasm, the proximal part of the bilateral optic
extending to the level of the frontal base was performed. The tracts, both internal carotid arteries, and the pituitary stalk
frontal lobes were retracted so that the LT was exposed (Fig. with the diaphragm sellae can be observed.
2).
Isolated brains were carefully removed during autopsies third-ventricular chamber laterally bordered by the pillars of
and were placed in 10% neutral buffered formalin for 3 weeks the fornix) (Fig. 3). The length, base, and area of the LT were
before examinations. Brains were sectioned in both the coro- calculated. The length, diameter, type, and frequency of ana-
nal and sagittal planes, for precise dissection and tomic variations and positions of the LT, relative to the ante-
measurements. rior cerebral artery (ACA), AComA, and perforating branches
The linear dimensions of the LT were calculated by consid- leading to the optic apparatus and hypothalamus, were ana-
ering the LT as a triangular structure with a height (the lyzed. Although the LT region was thoroughly examined
distance between the midportion of the posterosuperior sur- from all directions, particular emphasis was placed on obser-
face of the chiasm and the anterior commissure) and a base vations made from the perspective corresponding to the mi-
(the distance between the medial edges of the optic tracts, crosurgical pterional-transsylvian approach to the LT region.
representing the largest width of the surgical corridor to the In two injected, fresh, cadaveric heads, a rigid endoscope (0-
to 30-degree view; Karl Storz GmbH & Co., Tuttlingen, Ger-

FIGURE 3. Artist’s drawings, illustrating the LT base and

FIGURE 1. Cadaver photograph. In this fresh cadaveric head
specimen, a standard right pterional approach was used. The
LT is evident as a thin translucent membrane in a medial
position behind the optic chiasm. Both optic nerves, the
optic chiasm, the LT, the right internal carotid artery, and
the IIIrd cranial nerve can be observed.
height microanatomic measurements in the axial (a) and sag-
ittal (b) planes. The base was calculated as the distance
between the medial edges of the optic tracts, and the height
was calculated as the distance between the midportion of the
posterosuperior surface of the chiasm and the anterior com-
missure. See text and Table 2 for details. *, anterior commis-
sure; **, optic chiasm; A, base; B, height.

Neurosurgery, Vol. 50, No. 3, March 2002

 Microsurgical Anatomic Features of the Lamina Terminalis 565

many) was inserted through a supraorbital burr hole and

gently advanced, to provide a full endoscopic view of the
structures contained in the cistern of the LT (Fig. 4).

RESULTS
Approximately two-thirds of the anterior wall of the third
ventricle are visible on the external surface of the brain,
whereas the upper one-third is hidden behind the rostrum of
the corpus callosum (16). The part of the anterior wall ob-
served on the surface is formed by the optic chiasm and the
LT. The LT is a thin sheet of gray matter covered by a pial
layer that attaches, as a paper-thin membrane, to the upper
surface of the chiasm. The LT forms a sharp angle with the
wide flattened surface of the chiasm, giving rise to a recess
(the optic recess) bordered inferiorly by the upper surface of
the chiasm and ending in a bay on both sides, which leaves a FIGURE 5. Cadaver photograph. In this fresh cadaveric head
pit on the surface of the two optic nerves (Fig. 5). Although it specimen, the LT was exposed via a right pterional transsyl-
is variably developed, the LT constitutes the widest part of the vian approach and widely fenestrated. A right-angle smooth
third ventricle. The LT continues posteriorly and superiorly, hook elevates the most anterior portion of the LT, which
to fill the space between the chiasm and the rostrum of the forms a sharp angle with the wide flattened surface of the
corpus callosum. It becomes thicker in its upper part, leaves chiasm, giving rise to the optic recess.
the optic tracts, gradually enlarges to the maximal width, and
finally shrinks again to reach the anterior commissure.
The LT is intimately related to both A1 tracts of the ACA,
the AComA complex, both recurrent Heubner arteries, both
fronto-orbital arteries, arteries leading to the hypothalamus,
proximal A2 segments of the ACA, and the anterior commu-
nicating and anterior cerebral veins (Fig. 6). All of these struc-
tures are contained in the LT cistern, of which the LT is the
posterior boundary (17). The LT cistern communicates with
the chiasmatic cistern around the optic chiasm. Both cisterns
are contained in the anterior incisural space located above the
optic chiasm and limited superiorly by the rostrum of the
corpus callosum, posteriorly by the LT, and laterally by the
portions of the medial surfaces of the frontal lobes located
below the corpus callosum. The ACA, in its A2 portion, passes
in front of the LT and the anterior wall of the third ventricle,
to reach the rostrum of the corpus callosum in the anterior
portion of the corpus callosum cistern.
The observations concerning anatomic measurements and
neural and vascular relationships important for surgical ap-

FIGURE 4. Cadaver photo-

graph. In this fresh cadav-
eric head specimen, a
supraorbital burr hole was
produced and a 30-degree
rigid endoscope was
advanced into the cistern of
the LT. Full observation of
the LT and relevant adjacent
neurovascular structures
was achieved without
retraction of brain tissue.
The presence of a laterally placed perforating artery originat-
ing from the AComA and reaching the optic apparatus
should be noted.
FIGURE 6. Cadaver photograph. In this fixed cadaveric head
specimen, a bifrontal craniotomy extending to the level of
the frontal base was performed. The frontal lobes and the
AComA complex were retracted, and the LT was fully
exposed. In this preparation, the vascular structures con-
tained in the LT cistern, including the anterior communicat-
ing and anterior cerebral veins (injected in blue), can be
observed.
proaches to the LT region are presented separately. The re-
sults of microanatomic measurements, compared with the

Neurosurgery, Vol. 50, No. 3, March 2002

566 de Divitiis et al.

TABLE 1. Comparison of Previous Descriptions of the Lamina Terminalis and Its Neurovascular Relationshipsa
Yamamoto et al., 1981 Lang, 1985, 1992 Serizawa et al., 1997
Present Study
(16) (4, 5) (11)

Length of the LT (mm) 10 (8.0–12.0) 10.85 (5.0–16.0) Not reported 8.25 (7.0–10.0)
Base of the LT (mm) Not reported Not reported Not reported 12.81 (8.0–18.5)
2
Area of the LT (mm ) Not reported Not reported Not reported 52.84 (31.5–83.25)
AComA distance to the LT (mm) Not reported Not reported 30% over LT 3.5 (0–14)
a
AComA, anterior communicating artery; LT, lamina terminalis.

TABLE 2. Summary of Relevant Data on Lamina Terminalis Neurovascular Relationshipsa

Base (between the No. of
Distance between
Length (OC Lateral Margins of Area (Base ⫻ Height/2) AComA Length A1 Segment Heubner Artery Perforators
the AComA and
to AC) (mm) the Pillars of the (mm2) (mm) Length (mm) Origin from the
the LT (mm)
Fornix) (mm) AComA

8.25 (7–10) 12.81 (8–18.5) 52.84 (31.5–83.25) 2.9 (0.5–4.5) Left, 12.68 (10– A2 in 14 cases, A1 3.5 (0–14) 0 in 3 cases,
17); right, 14.25 in 4 cases, not 1 in 7 cases,
(10–20) identifiable in 2 2 in 5 cases,
cases 3 in 5 cases
a
OC, optic chiasm; AC, anterior commissure; AComA, anterior communicating artery; LT, lamina terminalis.

morphometric data found in the literature, are summarized in Vascular relationships

Table 1.
In our study specimens, the AComA complex was the
vascular structure most intimately related to the LT. The
Neural relationships distance between the two structures varied from 0 to 14 mm,
with an average of 3.5 mm. These differences depended on
The LT was observed in all specimens. As mentioned two main factors, i.e., anatomic anomalies of the AComA
above, full exposure of the LT and its neurovascular relation- complex and the degree of cerebral atrophy. For example, in
ships involves a component of retraction. Despite the subjec- the case exhibiting an estimated distance of 0 mm, an anom-
tivity in the determination of “allowable” retraction, only a alous plexiform AComA complex was located over the lower
minimal amount of retraction was needed to fully expose the one-third of the LT. In the case exhibiting the longest distance
LT in all fresh, unfixed, cadaveric brains studied. Endoscop- in this series (14 mm), the brain appeared atrophic, with wide
ically assisted exploration of the cistern of the LT, performed
without any retraction of neurovascular structures, allowed
full observation of the LT and relevant adjacent neurovascular
structures (Fig. 4).
The distance between the midportion of the upper edge of
the chiasm and the lower edge of the anterior commissure
(corresponding to the height) ranged from 7 to 10 mm, aver-
aging 8.25 mm. The distance between the medial edges of the
optic tracts, representing the largest width of the surgical
corridor laterally bordered by the pillars of the fornix (corre-
sponding to the base), varied from 8 to 18.5 mm, averaging
12.81 mm. The area ranged from 31.5 to 83.25 mm2, averaging
52.84 mm2 (Table 1). The distance between the front edge of
the brain and the LT is of interest for the subfrontal approach
to the hypothalamus and third ventricle. In our study speci-
mens, this distance ranged from 50 to 66 mm, with an average
of 58.5 mm. Variable locations of the optic chiasm in relation
to the tuberculum sellae (prefixed, normally fixed, and post-
fixed), as described by Renn and Rhoton (7), can occur. In our FIGURE 7. Photograph of an injected isolated brain prepara-
study specimens, we observed a normally fixed chiasm in all tion, demonstrating anomalies of the ACA-AComA complex.
except one case, in which a prefixed chiasm was noted, with- Three A2 segments originate from the AComA. The middle
out any significant differences in LT anatomic features or A2 segment is also called the medial artery of the corpus cal-
relationships with adjacent relevant neurovascular structures. losum or the precallosal artery.

Neurosurgery, Vol. 50, No. 3, March 2002

 Microsurgical Anatomic Features of the Lamina Terminalis
subarachnoid spaces and tortuous elongated arteries. By def-
inition, a normal AComA is one that connects two A1 seg-
ments of equal diameter. A normal, single-lumen AComA
was observed in 13 cadaveric brains (65%). The length of the
vessel ranged from 0.5 to 4.5 mm, averaging 2.9 mm. In the
remaining seven cadaveric brains (35%), several types of an-
atomic variations were observed, including triplication, plex-
iform characteristics, dimples, and in one case a medial artery
of the corpus callosum (Figs. 7 and 8). Anatomic variations of
the A1 segments also affected the relationships between the
ACA-AComA complex and the LT. In 40% (n ⫽ 8) of cases,
the ACA-AComA complex was eccentric to the LT because of
differences in length (⬎2 mm) between the ACAs of the two
sides. In all of these cases, the right ACA was longer than the
left ACA, so that the ACA-AComA complex appeared eccen-
tric to the left. From the AComA, small perforating vessels
arise that terminate in the whole anterior wall of the third
ventricle and reach the subcallosal, hypothalamic, and chias-
matic areas (11). In 14 of the 20 cases examined (70%), small
perforating arteries arose in variable number (one to three)
from the posteroinferior aspect of the AComA and entered the
area around the LT, to reach the hypothalamic and chiasmatic
areas. In our specimens, perforating branches passing through
the LT to enter the walls of the third ventricle were never
observed, with the exception of a single instance in which
three perforating branches arising from the AComA consti-
tuted a thick network of vessels that would have made it
virtually impossible to fully expose the LT without causing
vascular injury. In the other 95% of cases, perforator branches
directed to the hypothalamus and optic apparatus were lat-
erally placed and did not interfere with exposure, incision,
and fenestration of the LT (Fig. 9).
A precallosal artery has been reported to arise from the
AComA and pass upward in front of the LT, to proceed to the
rostrum of the corpus callosum (16). This variation was ob-
served in only one case among our study specimens (Fig. 7).
Another artery contained in the LT cistern is the Heubner
artery, which arose from the A2 segment immediately distal
FIGURE 8. Photograph of an injected isolated brain prepara-
tion, indicating anomalies of the ACA-AComA complex. A
triplicated AComA is shown.
Neurosurgery, Vol. 50, No. 3, March 2002
567
FIGURE 9. High-magnification view of a fresh cadaveric
head specimen. According to the description provided more
than one century ago by Retzius, “the slightly bulging lamina
terminalis extends. . . to the chiasm inferiorly and anteriorly.
In its middle a rhomboid or better pentagonal darker part is
seen, which is surrounded by a delicate frame and gives off a
whitish rod projecting upward. This is the transparent part of
the lamina terminalis, which I called fenestra laminae termi-
nalis” (8, p 56). The fenestra of the LT constitutes the mid-
line avascular area immediately above and posterior to the
chiasm, where incision and/or fenestration of the LT is to be
performed. Perforating branches of the ACA-AComA com-
plex directed to the optic apparatus and the hypothalamus
are positioned laterally and do not interfere with the surgical
procedure.
to the AComA in 28 of 40 A2 segments (70%) examined in our
series, arose from the A1 segment in 8 of 40 A1 segments
examined (20%), and was not recognized in 2 of 40 cases (on
the right side in one case and on the left side in another case).
DISCUSSION
Surgical exposure, incision, and wide fenestration of the LT
have become critical components of many contemporary neu-
rosurgical approaches (2, 3, 6). Knowledge regarding the mi-
crosurgical anatomic features and vascular and neural rela-
tionships of this structure is important for enhancement of the
safety and efficacy of these approaches. According to the
description provided more than one century ago by Retzius:
. . . the slightly bulging lamina terminalis extends from
the divergent subcallosal gyri to the chiasm inferiorly
and anteriorly. In its middle a rhomboid or better pen-
tagonal darker part is seen, which is surrounded by a
delicate frame and gives off a whitish rod projecting
upward. This is the transparent part of the lamina ter-
minalis, which I called fenestra laminae terminalis. Like
most other rudimentary parts, the fenestral membrane
is variably developed. It may be quite large or of mod-
erate size. In some cases it is, however, indistinct and
less transparent or reduced to a slender midline gap of
variable shape closed by the fenestral membrane. What-
ever its size and development, the lamina terminalis
cerebri is of considerable morphological interest. Leav-
ing aside the choroid plexus, it is one of the thinnest
structures of the brain wall, but with a reinforcement on
568 de Divitiis et al.
its outer aspect by the firmly attached pia mater (8, p
56).
Rhoton et al. (9, 10, 16) described the microsurgical ana-
tomic features of the third ventricle and the relevant surgical
approaches. They provided accurate measurements of the
distance from the upper edge of the optic chiasm to the
anterior border of the anterior commissure, corresponding to
the length of the LT. Those authors recommended the LT
approach for tumors located above the sella turcica and below
the foramen of Monro, in the anteroinferior part of the third
ventricle, especially tumors that have pushed the chiasm into
a prefixed position and have distended and stretched the LT
(10). They also emphasized the importance of preserving the
perforating branches penetrating the anterior wall of the third
ventricle during retraction of the ACA-AComA complex to
expose the LT. With respect to the neural relationships of the
LT, those authors recommended meticulous attention in
opening the thinned LT, to prevent damage to the anterior
commissure and the rostrum of the corpus callosum above,
the optic chiasm below, and the optic tracts, the columns of
the fornix, and the hypothalamic walls laterally. Regarding
the LT approach to the anterior third ventricle as a portion of
the subfrontal exposure, Stein (13) called attention to the
vascular supply of the dorsum of the optic chiasm in this
region. There are important anastomotic branches from the
AComA and ACA that might be interrupted or injured by
such an approach.
The LT between the upper edge of the optic chiasm and the
lower edge of the anterior commissure was 10.85 mm (5.0–16
mm) long in the study specimens described by Lang (4).
Behind the LT lies the entrance to the recessus opticus, which
was 3.66 mm (1.0–6.5 mm) long, and the entrance to the
recessus infundibuli, which exhibited a length of 6.02 mm
(3.5–9.0 mm). The distance from the ACA, pars postcommu-
nicalis, to the LT measured 2 to 9 mm in the specimens
studied by Lang (4). The distance between the front edge of
the brain and the LT ranged from 53 to 65 mm, with an
average of 59.3 mm. More recently, Serizawa et al. (11) re-
viewed the microsurgical anatomic features of the AComA
and its perforating branches, to demonstrate their importance
for the interhemispheric trans-LT approach and AComA an-
eurysm surgery. In 30% of the cadaveric brains examined, the
AComAs covered the lower one-third of the LT, chiefly be-
cause of anomalies such as duplication and plexiform-type
AComAs.
When our results are compared with the descriptions by the
authors cited above, certain similarities but some differences
and additional morphometric data can be noted. Our descrip-
tion of the height of the LT is in accordance with the findings
of the aforementioned authors. The base and area of the LT,
however, have not previously been reported. With respect to
the relationship between the LT and the AComA complex,
there are discrepancies between the data reported by
Serizawa et al. (11) and our findings. Finally, with respect to
the AComA perforating branches, Yamamoto et al. (16) re-
ported that the AComA gives rise to a series of perforating
arteries that may 1) enter the area of the LT, 2) pass through
the LT to enter the walls of the third ventricle, and 3) pass
Neurosurgery, Vol. 50, No. 3, March 2002
upward in front of the LT to supply the rostrum. In our
specimens, the perforator branches directed to the hypothal-
amus and optic apparatus were laterally placed in the large
majority of cases and did not interfere with exposure, incision,
and fenestration of the LT (Fig. 9).
Several approaches to expose the anterior part of the third
ventricle have been described in the literature. To gain a wide
access corridor to this region with minimal brain retraction and
without incision of neural structures, the trans-LT route via a
pterional, subfrontal, or interhemispheric approach can be used.
This route has been described more frequently for craniophar-
yngiomas (3, 6) and for a wide spectrum of pathological entities
located within the anterior third ventricle or invading or com-
pressing the walls of the chamber (1), but intrinsic lesions of the
hypothalamus can also be successfully removed via this route
(2). A discussion of the relative advantages and disadvantages of
the different surgical approaches to the LT region is beyond the
scope of this article. Recent work, however, has favored the
interhemispheric trans-LT approach to the anterior third ventri-
cle, as in surgery to treat craniopharyngiomas (3). Results of
microanatomic studies of the AComA, its branches, and its vari-
ations, as encountered during such an approach, led to the
conclusion that the anterior interhemispheric approach is better
than the pterional approach for identifying and preserving these
structures (11). As discussed above, our observations do not
substantiate these findings, and they corroborate the opinion of
Yaşargil (18) that both of the A1 segments, the AComA, and the
proximal portions of the A2 segments and their branches can be
identified and preserved precisely during the pterional-
transsylvian approach to the LT region for tumor exploration or
AComA aneurysm surgery.
A second surgical issue to be considered is related to the
observations that fenestration of the LT during microsurgical
procedures for ruptured aneurysm clipping has favorable effects
on outcomes, because of the decreased incidence and severity of
delayed vasospasm (12) and chronic post-subarachnoid hemor-
rhage hydrocephalus (14, 15, 19). The concept was recently sub-
stantiated by clinical investigations by our group, which pro-
vided evidence that the incidence of clinically significant
hydrocephalus could be reduced after wide LT fenestration (14,
15). The results of the present investigation support the conclu-
sions derived from the clinical experience, i.e., that a standard
pterional trans-LT approach is a simple, safe, effective method to
identify anatomic landmarks and fully expose the LT, with min-
imal retraction of important neurovascular structures. In this
respect, the results of endoscopically assisted exploration of the
cistern of the LT demonstrated the feasibility of fully exposing, in
normal brain, the LT and adjacent neurovascular structures
without tissue retraction. The perforating branches of the ACA-
AComA complex are laterally placed with respect to the optic
apparatus and do not interfere with the fenestration procedure
(Fig. 9). Moving from the chiasm below to the anterior commis-
sure above, anteriorly to posteriorly, the LT leaves the optic
tracts, gradually enlarges to the maximal width, and finally
shrinks again to reach the anterior commissure. This particular
shape must be kept in mind during surgery through the LT;
opening of the LT must be performed in the lowest portion on
the midline, immediately above and posterior to the chiasm. This
 Microsurgical Anatomic Features of the Lamina Terminalis
FIGURE 10. Cadaver photograph. In this fresh cadaveric head
specimen, the LT was exposed via a right pterional transsylvian
approach and widely fenestrated. Opening of the LT must be
performed in the lowest portion on the midline, immediately
above and posterior to the chiasm. This allows access to the
anterior portion of the third ventricle. The allowable extent of
LT opening is sufficient to provide wide access into and free
cerebrospinal fluid flow from the third ventricle.
allows access to the anterior portion of the third ventricle with-
out adjunctive damage to the pillars of the fornix and the ante-
rior commissure (Fig. 10). The hypothalamus is not in a direct
relationship with the LT but is closely related laterally, and
injury to this region may be caused by pressure and manipula-
tion (unilateral injury is rarely clinically symptomatic).
CONCLUSIONS
We have detailed the anatomic features of the LT and its
neurovascular relationships. The main conclusions from our
study are as follows: 1) the LT constitutes a clearly identifiable
microsurgical target; 2) a minimal amount of retraction is
needed to fully expose the LT, and there is generally no need
to mobilize the ACA-AComA complex; 3) perforating
branches to the hypothalamus and optic apparatus are later-
ally located and do not interfere with LT incision and/or
fenestration; 4) the allowable extent of LT opening is sufficient
to provide wide access into and free cerebrospinal fluid flow
from the third ventricle; and 5) fenestration of the LT is a safe
procedure, provided that the relevant anatomic landmarks
are identified and respected.
ACKNOWLEDGMENTS
This work was supported in part by grants from the Min-
istero dell’Università e della Ricerca Scientifica e Tecnologica
(Piano B008, Progetto 2) and the European Community (Grant
9906141521). We acknowledge Sabrina Sunna for artistic
drawings.
Received, January 2, 2001.
Accepted, October 17, 2001.
Reprint requests: Domenico d’Avella, M.D., Neurosurgical Clinic,
Policlinico Universitario, via Consolare Valeria 1, 98122 Messina,
Italy.
Email: davellan@unime.it
Neurosurgery, Vol. 50, No. 3, March 2002
569
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COMMENTS
The authors have presented an excellent study of an im-
portant route to the anterior part of the third ventricle and
570 de Divitiis et al.
have beautifully illustrated the area. They note that the pte-
rional approach provides satisfactory access to the lamina
terminalis (LT), as for aneurysm treatment, in which there is
only a need to open the LT to release fluid from the ventricle.
However, a subfrontal exposure directed near the midline is
required to access the depths of the third ventricle, as needed
for third-ventricular tumor removal. When the LT is opened
in the pterional approach, the view is toward the opposite
optic tract, rather than back to the long axis of the third
ventricle between the columns of the fornix and above the
mamillary bodies. For subarachnoid hemorrhage treatment,
in which only fenestration of the LT is needed, a pterional
approach is adequate; for midline third-ventricular tumors,
however, the view is improved nearer the midline. When
there is a prefixed chiasm and a third-ventricular tumor must
be removed through the LT, we use a subfrontal approach
with the medial border of the exposure on the superior sag-
ittal sinus. The more laterally toward the pterional route that
the exposure is shifted, the less adequate is the exposure for
tumors within the third ventricle. In the pterional approach,
the opening through the LT is directed toward the contralat-
eral optic tract, rather than into the ventricular cavity. In most
cases, the anterior cerebral and anterior communicating arter-
ies must be gently elevated to expose the upper margin of the
LT. In most cases, it is easier to expose the LT below, rather
than above, the anterior communicating artery. The authors
have presented an excellent study of this area.
Albert L. Rhoton, Jr.
Gainesville, Florida
de Divitiis et al., in this concise and well-written article,
present their anatomic review of the LT, with particular at-
tention to the surgical anatomic features of this region. Until
1973, the development of malresorptive hydrocephalus could
be evaluated on the basis of the course of the pericallosal
arteries and the internal cerebral veins in angiograms (acute
hydrocephalus) or pneumoencephalograms (chronic hydro-
cephalus), usually 3 to 4 weeks after the initial hemorrhage.
The value of assessing the extent of hydrocephalus with ech-
oencephalography and radioimmunosorbent assay cisternog-
raphy was more limited, however. The availability of com-
puted tomography (in 1973) and magnetic resonance imaging
(in 1986) facilitated the study and evaluation of morphological
changes of the ventricular system.
Neurosurgery, Vol. 50, No. 3, March 2002
The microtechnical exploration and evacuation of blood from
the basal cisterns, particularly the sylvian, chiasmatic, interpe-
duncular, and prepontine cisterns, together with fenestration of
the LT in cases of coagulated and adherent hematomas was
observed, in the experience of the senior commentator (MGY), to
be helpful in reducing the incidence of shunting procedures to
8.6% (in 1984). In 1983, the senior commentator began to regu-
larly fenestrate the LT for all patients with ruptured aneurysms
(665 cases between 1983 and 1992) and observed a reduction in
the incidence of shunting procedures to 3.0%. With the assump-
tion that in some cases the fenestrated LT may later be occluded
with scar tissue, we recommend sharply opening the LT with
fine-tip bipolar coagulation forceps and briefly coagulating the
opened rim of the LT, to avoid future adhesions.
M. Gazi Yaşargil
Little Rock, Arkansas
Saleem I. Abdulrauf
St. Louis, Missouri
The authors provide valuable morphometric data on the
microsurgical anatomic features of the LT. In our opinion,
knowing the distance between the lateral boundaries of the LT
is of great importance for surgical procedures performed in
this small, highly sensitive area of the brain, especially for
tumors involving the anterior third ventricle. Also, precise
localization of the safe area for fenestration could be easily
performed. We do not necessarily agree with the authors that
the pterional approach is more convenient than the interhemi-
spheric approach to the LT region for both tumors and vas-
cular lesions. We have observed the interhemispheric ap-
proach to be safer and easier, in many cases, for observation
and preservation of the vascular structures related to the LT
and for removal of tumors in the anterior third ventricle.
Shigeaki Kobayashi
Hossam El-Noamany
Matsumoto, Japan
This is a straightforward cadaveric dissection study of the
anatomic structures surrounding the LT. Surgical approaches
through the LT provide a safe convenient strategy for the
removal of many third-ventricular tumors. By emphasizing
this structure in their nicely illustrated report, the authors
demonstrate how direct and useful these approaches can be.
Jeffrey N. Bruce
New York, New York