Technical Note
Venous-Preserving Sylvian Dissection
Hidetsugu Maekawa and Hiromu Hadeishi
- OBJECTIVE: The Sylvian fissure has been dissected
through the frontal side of the superficial Sylvian veins with
sacrifice of the tributaries of the frontal superficial Sylvian
vein, which may lead to venous infarction. In addition,
disturbed venous drainage makes the brain susceptible to
brain retraction. Therefore, preservation of the vein is
essential in modern neurosurgery to decrease morbidity.
- METHODS: We describe the technical nuances of Syl-
vian dissection with an emphasis on preserving the veins.
- RESULTS: The arachnoid between the frontal and tem-
poral superficial Sylvian veins is divided as to enter the
fissure. After the deep part in the Sylvian fissure is
reached, the inside of the fissure is dissected along the
“microvascular Sylvian fissure,” the temporal side of the
frontal vessels or the frontal side of the temporal vessels.
The Sylvian fissure is dissected in a deep-to-superficial
and posterior-to-anterior fashion (“paperknife technique”)
up to the skull base. The frontal superficial Sylvian vein
usually tethers the brain to the dura, restricting the surgical
corridor when approaching deep lesions. Peeling off the
arachnoid that wraps this vein (“denude technique”)
allows the vein to stretch.
- CONCLUSIONS: Keeping the proper dissection plane
(“microvascular Sylvian fissure”) is crucial to preserve the
veins. The “paperknife technique” makes the division of
the frontal and temporal lobe easier. The “denude tech-
nique” provides a wider space between the frontal lobe
and the skull base. These techniques make it possible to
obtain a sufficiently wide surgical corridor to the basal
cistern without sacrificing the veins and their tributaries.
Key words
- Superficial Sylvian vein
- Surgical technique
- Sylvian fissure dissection
- Transsylvian approach
- Venous sacrifice
Abbreviations and Acronyms
CT: Computed tomography
WORLD NEUROSURGERY 84 [6]: 2043-2052, DECEMBER 2015
INTRODUCTION
T
he Sylvian fissure lies between the frontal and temporal
lobes from lateral to medial, making it possible to
approach the deep lesions through this fissure. Sylvian
dissection is one of the requisite skills for microneurosurgeons,
because the Transsylvian approach, combined with fronto-
temporal craniotomy and its modifications, is one of the most
versatile and commonly performed approaches (3, 6, 7, 13, 19).
The superficial Sylvian veins, one of the three dominant venous
drainage systems of the lateral cerebrum, lie on the surface of
the Sylvian fissure. They usually drain into the dural sinus along
the sphenoid wing. In other words, they bridge the brain and the
dura, which can obstruct the surgeon’s perspective or prevent
the brain from retracting. Therefore, the superficial Sylvian veins,
especially the frontal superficial Sylvian veins, are occasionally
sacrificed during dissection (13, 15, 19). Venous infarction or
severe cerebral edema caused by venous congestion may follow,
resulting in neurologic deficits (11, 15, 17).
Considering it is difficult or impossible to foresee the conse-
quence of sacrificing the veins, the surgeon should endeavor to
save the superficial Sylvian veins while reserving a wide enough
space within the surgical field for safe manipulation. Few tech-
niques to preserve these veins, however, have been described
(5, 12, 18). We think that identification of the correct dissecting
plane is of great importance. Several tips and tenets described
here are useful to save the veins.
MATERIALS AND METHODS
We describe technical nuances for dissection of the Sylvian fissure
with an emphasis on preserving the superficial Sylvian veins. We
usually split the lateral Sylvian fissure widely in a distal (lateral-to-
medial) fashion, even for deep lesions around the basal cisterns, but
we believe that at least a part of this technique can be applied to the
proximal (medial-to-lateral) transsylvian approach or an approach
with a small Sylvian opening (3).
Department of Neurosurgery, Kameda Medical Center, Kamogawa, Chiba, Japan
To whom correspondence should be addressed: Hiromu Hadeishi, M.D., Ph.D.
[E-mail: hade@kameda.jp]
Citation: World Neurosurg. (2015) 84, 6:2043-2052.
http://dx.doi.org/10.1016/j.wneu.2015.07.050
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
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TECHNICAL NOTE

Between April 2011 and March 2015, we operated on 66
unruptured middle cerebral and internal carotid artery aneurysms
(40 and 26, respectively). We reviewed the operative reports and
videos to decided whether we could split the Sylvian fissure
completely (as far as we needed). We also evaluated pre- and
postoperative computed tomography (CT) scans to identify any
low-density areas around the Sylvian fissure. We considered that
patients with intracranial tumors and subarachnoid hemorrhage
who underwent operation via the Sylvian approach were not
suitable for this analysis because the lesion itself could cause
brain damage and edema.
RESULTS
Techniques for Venous-Preserving Sylvian Dissection
Craniotomy. The patient is placed in the supine position with the
head rotated and the neck extended according to the location of
the lesion. A typical frontotemporal craniotomy is made, and the
greater wing of the sphenoid bone is removed. The dura is
opened by a semicircular incision, revealing the Sylvian fissure
and the frontal and temporal lobe. Then, we introduce an oper-
ative microscope for Sylvian dissection.
Opening the Surface of the Sylvian Fissure between the Superficial
Sylvian Veins. The superficial Sylvian veins vary in size and
number among patients and between the 2 sides of the same
brain. The typical superficial Sylvian veins course along the
Sylvian fissure to the dural sinus along the sphenoid wing
(Figure 1A, D), and there may be no superficial Sylvian vein
present in some cases. In our experience, 2 stems (frontal
and temporal) of the superficial Sylvian veins emptying into
the venous sinus are generally identified (16). Each
superficial Sylvian vein usually receives blood from either the
frontal or temporal side of the fissure. Therefore, the Sylvian
fissure should be split between the frontal veins and
temporal veins (Figure 1B, E). Otherwise, the surgeon
encounters a vein crossing the surgical corridor between the
frontal and temporal lobe, interfering with the dissection. In
such cases, this vein is sacrificed in traditional Sylvian
dissection (13, 19), which may result in venous infarction
(Figure 1C, F).
Before starting the dissection, we first observe the course and
tributaries of the superficial Sylvian veins to decide through
which plane to enter the fissure (Figure 2A). Then, we open the
outer arachnoid membrane (8) about 3 cm from the sphenoid
ridge with a 27-gauge needle applied on the tip of a 1-ml
syringe (Figure 2B). Making this notch helps the surgeon hold the
arachnoid with jeweler’s forceps in both hands and to tear it
towards the skull base (Figure 2C). The use of forceps is easier
and faster than the use of microscissors and a suction tube.
This manipulation is advanced in small increments to avoid
excess tension on the structure around the arachnoid (e.g., the
fragile tributaries of the superficial Sylvian veins). As previously
reported, the superficial Sylvian veins are interposed between

Figure 1. Venous-saving superficial Sylvian dissection. (A) The proper dissection plane is between the frontal and
temporal superficial Sylvian veins (red line). (B) The tributaries of the frontal superficial Sylvian vein are preserved when
the Sylvian fissure is dissected appropriately. (C) To achieve Sylvian dissection through the frontal side of the frontal
superficial Sylvian vein (red line), all its tributaries are sacrificed. Venous congestion (purple area) may cause
subsequent neurologic decline. (D) When the frontal superficial Sylvian vein (F) runs on the temporal lobe, the
appropriate dissection plane (red line) is between the frontal and temporal (T) superficial Sylvian veins and between the
frontal vein and the temporal lobe. Note that some frontal tributaries also may run on the temporal lobe. These veins
should be dissected from the temporal lobe. (E) These veins are preserved when the dissection is done through the
appropriate plane. (F) Dissecting the Sylvian fissure through the frontal side of the frontal veins appears simple but
requires cutting these veins, which may lead to venous congestion.

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 TECHNICAL NOTE

Figure 2. Opening the surface arachnoid of the left Sylvian fissure. (A) Three superficial Sylvian veins can be seen. The
veins on the left and in the middle receive blood from the temporal side, whereas the vein on the right receives blood
from the frontal side of the Sylvian fissure (arrows). In this case, the Sylvian fissure is opened between the veins on the
right and in the middle (dashed arrow). (B) The outer arachnoid membrane is cut with a 27-gauge needle. The arachnoid
is under some tension, which is exerted with the suction tube. (C) After a slit is made, the arachnoid is torn with
jeweler’s forceps. (D) A frontal tributary of the superficial Sylvian vein (arrow) disturbs the surgical field. The arrow
indicates the frontal vein joining the superficial Sylvian vein at the tip of the forceps. In this case, the temporal side of
the vein, which is a frontal superficial Sylvian vein (arrowhead), should be dissected (dashed arrow). (E) The temporal
side of the frontal superficial Sylvian vein (arrowhead) is opened. The arrowhead indicates the identical frontal
superficial Sylvian vein in (D).

the two layers of the arachnoid membrane: the outer membrane
and the lateral Sylvian membrane (8).
It is sometimes difficult to predict the proper dissection plane
correctly. When the operative view is obstructed by the tribu-
taries of the superficial Sylvian vein or the superficial Sylvian vein
itself, it usually means that the wrong plane is being divided
(Figure 2D). In this case, another plane, usually the plane next to
the dissected plane, is opened (Figure 2E). The proper
dissection plane is between the frontal and temporal superficial
Sylvian veins in some cases and between the brain and the
vein in other cases. For example, the plane between the
temporal lobe and the frontal superficial Sylvian veins is
the appropriate plane in cases with no temporal superficial
Sylvian vein (Figure 3).
In many cases, the superficial Sylvian veins do not run in the
center of the Sylvian fissure; rather, they run on the temporal
lobe. If the frontal Sylvian veins course on the temporal lobe, the
dissection plane is between the frontal veins and the temporal
lobe (Figures 1D and 3A). These veins need to be detached from
the temporal lobe (Figure 1E), which is sometimes troublesome.
In this situation, the temporal artery crossing under the
superficial Sylvian vein is the key (Figure 3B). It is easier to start
the dissection from the point at which the artery courses under
the vein than at any other points because the vein is usually
dissected more easily from the artery than from the brain. The
vein is lifted with forceps to provide tension to the arachnoid
between the vein and artery (Figure 3C). The forceps or
microscissors in the other hand can be used to dissect this
arachnoid. These instruments are used to widen the space:
they are inserted deep with the tip closed and then the tip is
opened slightly. After a cleavage plane is made, the vein is
easily dissected from the surface of the brain, and the
dissection plane is opened (Figure 3DeE). We prefer jeweler’s
forceps rather than bipolar forceps because jeweler’s forceps
have thinner tips and are lighter without a cable.
Microvascular Sylvian Fissure. After opening the outer arachnoid
membrane, the surgeon enters the Sylvian fissure from the point at
which a notch has been made on the outer arachnoid membrane
with a needle. Then, the dissection of inside the Sylvian fissure
progresses toward the skull base. The M1, M2, and M3 portions of
the middle cerebral artery run in the Sylvian fissure. Although some
of the middle cerebral arteries are rather tortuous, there is no artery
distal to the main bifurcation supplying both the frontal and temporal
lobes. Similarly, like the superficial Sylvian veins, each vein inside the
Sylvian fissure generally drains blood from either the frontal or
temporal lobe. This means, theoretically, that the Sylvian fissure can
be dissected between the frontal arteries and temporal arteries and
between the frontal veins and temporal veins without sacrificing any
vessels. We term this plane the “microvascular Sylvian fissure.” The
Sylvian fissure is split along the microvascular Sylvian fissure; the
temporal side of the frontal vessels or the frontal side of the tem-
poral vessels is dissected. When vessels appear to bridge 2 lobes,
the lobe that the vessels belong to is confirmed through careful
inspection and dissection (Figures 4 and 5). It is essential to
identify which lobe the vessel belongs to in order to keep the
proper route.

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TECHNICAL NOTE

Figure 3. Mobilizing the frontal superficial Sylvian veins from the right temporal lobe to enter the Sylvian fissure through
the proper plane. (A) The frontal superficial Sylvian vein courses and attaches to the temporal lobe. (B) A temporal
artery (arrowhead) runs under the frontal superficial Sylvian vein (arrow). In this case, the space between the frontal
superficial Sylvian vein and the temporal lobe should be opened. The point at which these vessels cross (arrowhead) is
key. (C) The adhesion between the superficial Sylvian vein and the temporal artery is loose, making it easier to dissect
the vein from the artery than from the brain. (D) The arachnoid between the vein and the temporal lobe is cut up to the
skull base. (E) The superficial Sylvian veins are detached completely from the temporal lobe and are mobilized to the
frontal side. Note that no vein obstructs the surgical corridor.

Paperknife Technique. In the Sylvian fissure, the frontal and tem- done in the proximal transsylvian approach. After the deep part is
poral lobes usually adhere to a greater degree in the superficial entered, the dissection is advanced from the deep part to the
part than in the deep part. Therefore, it is often difficult to split superficial part in small increments toward the skull base while
the superficial part of the fissure from the outside as is otherwise the retractor is repositioned frequently, as described in the

Figure 4. The microvascular Sylvian fissure. Intraoperative photograph of the right Sylvian fissure. (A) Complicated
course of the vessels inside the Sylvian fissure makes it difficult to determine where to dissect, which may motivate
surgeons to sacrifice vessels. Careful observation of the course of the veins (arrowheads) helps understand which lobe
these veins belong to. These are a continuous temporal vein attached to the frontal lobe. The proper path of the
dissection here is the frontal side of the vein. (B) After the arachnoid between the temporal vein and the frontal lobe is
cut, the surgical corridor becomes clear and wide. Arrowhead indicates the same temporal vein in (A).

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 TECHNICAL NOTE

Figure 5. Intraoperative photographs of a right middle cerebral artery aneurysm. (A) The Sylvian fissure has been
dissected from the space between the frontal lobe and the superficial Sylvian veins. A small vein inside the Sylvian
fissure (white arrow) runs on the aneurysm, interfering with further dissection of the aneurysm. This vein belongs to
the frontal lobe and is a tributary of the frontal superficial Sylvian vein (black arrow). This means that the Sylvian fissure
is opened through the wrong plane between the frontal lobe and the frontal vein. (B) To follow the proper dissection
plane, this frontal vein (white arrow) together with the frontal superficial Sylvian vein (black arrow) is dissected from the
temporal lobe and moved to the frontal side. (C) After these manipulations, a clear surgical corridor for dissection and
clipping of the aneurysm is obtained, and the small frontal vein is preserved. The black arrow indicates the identical
frontal superficial Sylvian vein as indicated with the black arrow in (A).

section “Appropriate and Effective Use of a Brain Retractor.”
This manipulation is done through a narrow working area when
the frontal and temporal lobes adhere tightly. Intense retraction
of the brain to widen the surgical corridor to a degree that is more
than necessary should be avoided. Cutting the arachnoid
releases the adhesion of the frontal and temporal lobes, making
the dissection of the superficial part and more proximal part of
the fissure easier. We call this method the “paperknife tech-
nique” because it is similar to opening an envelope with a
paperknife (Figure 6). This technique is particularly useful around
the limen insulae, where the brain usually adheres strongly.
When the dissection of the Sylvian fissure is completed up to the
most anterior part, the lateral Sylvian cistern is fully opened, and
the bifurcation of the middle cerebral artery and the limen insulae
can be seen clearly.

Denude Technique. For surgery involving deeper lesions, such as

Figure 6. Paperknife technique. After the deep part of the Sylvian fissure
is entered, the dissection proceeds in a deep-to-superficial and distal-to-
proximal manner. This manipulation is occasionally advanced within a
narrow corridor. The tips of the retractor and the suction tube are placed
close to the working area and deep in the fissure, as described below
(see the section “Appropriate and Effective Use of a Brain Retractor”),
providing a clear and wide operative field with minimal retraction.
M1, internal carotid aneurysms, basilar artery aneurysms, and
skull base tumors, the surgical corridor involves the space
between the skull base and the brain. The bridging veins running
from the frontal lobe to the dura to drain into the dural sinus
usually obstruct the operative field. In addition, they tether the
brain and the dura (Figures 7A and 8A). These veins are wrapped
with thick and tough arachnoid, which is hard to extend.
Removing this arachnoid makes the vein more stretchable,
providing a wider surgical corridor to approach deep structures
(Figure 7B). To clear this arachnoid, the arachnoid is gently
peeled away from the vein with two forceps in both hands
(Figure 8B). Then, the peeled arachnoid is cut off with
microscissors. We call this maneuver, the “denude technique.”
The surgical corridor can be widened more by dissection of the
veins from the part of the brain where they leave the brain
(Figure 7). Through these manipulations, followed by dividing
the arachnoid between the frontal lobe and the skull base
and the arachnoid around the most proximal M1, the dissection
of the Sylvian fissure is completed. The optic nerve and the
internal carotid artery can be seen (Figure 8C, D).
Occlusion of the vein may occur even if it is anatomically pre-
served. To preserve the vein functionally, it is necessary to avoid
excessive compression, stretching, or torsion on the vein by the
retractor or surgical instruments that could otherwise obstruct
blood flow in the vein and lead to permanent occlusion.

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TECHNICAL NOTE

Figure 7. The effect of the “denude technique” and dissection of the vein from the brain. (A) The space between the
brain and the skull-base dura is narrow (black bidirectional arrow). The arachnoid wrapping the veins is removed, and
the segment of the veins indicated by red lines is detached from the brain. (B) The denude technique allows the vein to
extend (the segment between the skull base and red dashed line), and freeing the vein from the brain allows the vein to
lift (indicated by red lines) when the brain moves away from the skull-base dura. Note that the space between the brain
and the skull base is enlarged (black bidirectional arrow).

Appropriate and Effective Use of a Brain Retractor. When dissecting
inside the Sylvian fissure, we often use a self-retaining retractor.
A retractor is placed to provide some tension on the arachnoid to
be cut and to move the superficial Sylvian veins or the brain
laterally from the working field. The retractor should be used
appropriately in combination with a suction tube to obtain a suf-
ficiently wide (but not too wide) and clear working area
(Figure 9A). We (all right-handed) prefer to place a retractor on the
right side of the operative field because we can use the suction
tube in the left hand to retract the structures on the left
(Figure 10). If needed, another retractor can be placed on the left
side. Excessive retraction produces a wide space, but this should
be avoided because it compresses and damages the brain tissue.
Excessive tension on the arachnoid is transmitted to the tiny
vessels around the arachnoid, avulsing them and causing
bleeding. The retraction by the retractor has to be minimized.
The retractor often works well when it is placed to only
stabilize the adjacent structures against retraction from the
suction tube rather than to actually retract them.
The position of the retractor is also important for its effective and
safe use (Figure 9B). When the retractor is placed far from the
working area, stronger retraction will be necessary to achieve
its purpose. Therefore, we frequently move the retractor close
to the area to be dissected. The tip of the retractor is placed
deep enough in the Sylvian fissure to reduce the retraction of
the brain. The direction of the retraction is sometimes essential
for the effective use of the retractor. The tension in the
vessels or the arachnoid changes considerably according to the
direction of brain retraction. The retractor can be used to hold
the brain in the horizontal direction as well as in the oblique
and vertical directions (Figure 10).
Clinical Results
The outcomes of the 66 patients, except 1, were good without
any complications. A perioperative complication associated with
Sylvian dissection was observed in one case with a middle
cerebral artery aneurysm (postoperative hemorrhage resulted
from cortical artery injury). Although this patient required another
surgery, he did not have any neurologic deficit.
In 3 patients (4.5%) with a single superficial vein, we could not
divide the frontal and temporal lobes thoroughly. Although some
frontal tributaries draining into the Sylvian vein obstructed the
surgical field, we could successfully place a clip on the aneu-
rysms through the corridor between the tributaries without
scarifying them. None of the patients had edema around the
aneurysm on preoperative CT. On postoperative CT, we could
not identify any low-density area suggesting edema or contusion.
DISCUSSION
This report described technical nuances of venous-preserving
Sylvian dissection, which is different from the conventional Syl-
vian split with sacrificing of the frontal veins. Accurate recogni-
tion of the anatomy of the superficial veins and “microvascular

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Figure 8. Denude technique. Intraoperative photographs showing the right distal Sylvian approach. (A) The frontal superficial
Sylvian vein (arrow) bridge between the frontal lobe and skull base to drain into the sphenoparietal sinus. (B)The thick
arachnoid on this vein (arrow) is peeled off by the use of 2 forceps and is removed. (C, D) After this manipulation, the vein
(arrow) can be stretched more than before. Note that the suction tube in the left hand is introduced from the left side to this
vein while the microscissors or the bipolar forceps in the right hand is introduced from the right side to this vein to avoid
tearing the vein by excessive tension.

Figure 9. Appropriate use of a retractor. (A) A sufficiently wide working area (red circle) is established with a retractor and a
suction tube. Obtaining a working area larger than necessary (red dashed ellipse) means that the brain is retracted more,
which damages the brain and the venous outflow. The surgeon should avoid too much retraction, especially when the frontal
and temporal lobes adhere tightly. Blue lines indicate the surface of the brain being retracted. (B) Retractors placed in the
appropriate position (1) and inappropriate position (2). Retractors 1 and 2 are applied to obtain the working area (red circle). The
position of retractor 1 is close to the working area, requiring less retraction of the brain (blue arrow 1). In contrast, retractor 2,
placed away from the working area, requires more retraction (blue arrow 2) to obtain the same space. To reduce brain
retraction, the retractor must be placed close to the working area and is frequently moved as the dissection advances.

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Figure 10. Effective use of a retractor. Intraoperative photograph of the left Sylvian fissure. (A) A retractor is placed on the
left frontal superficial Sylvian vein (arrowhead) to hold it laterally. The tension of the arachnoid can be adjusted with the
suction tube, making it easy to cut the arachnoid. (B) The dissection proceeds toward the skull base without moving the
retractor, which is placed away from the operative field (the tip of the microscissors). Note that the frontal Sylvian vein
(arrowhead) is attached to the temporal lobe. (C) After placement of the retractor close to the working area, the anatomical
relationship between the vein (arrowhead) and the arachnoid becomes easy to understand, and the arachnoid between the
vein and the temporal lobe can be safely cut with microscissors. Note that the direction of the retraction is to the upper
right, which results in a clear view for the surgeon without increasing the retraction. (D) The dissection of the frontal Sylvian
vein (arrowhead) has been almost completed. The vein is detached from the temporal lobe without sacrificing it. Note that
this vein does not empty into the superficial Sylvian vein or the dural sinus.

Sylvian fissure” helps the surgeon find the best dissection plane.
This plane may be between the frontal vessels and the temporal
vessels, between the frontal lobe and the temporal vessels, or
between the temporal lobe and the frontal vessels. In the classic
frontal-sided Sylvian split, all of the inferolateral frontal tributaries
of the superficial Sylvian veins often are pruned away, which may
lead to neurological complications (1, 13, 19). To preserve these
veins, the Sylvian fissure is divided according to the course and
tributaries of the veins. The Sylvian fissure is separated by the
“paperknife technique.”
Deep-seated lesions around the basal cistern are approached
through the route between the brain and the skull base. To
obtain a wide corridor, the position of the head, sufficient
removal of the sphenoid wing, arachnoid dissection to untether
the brain from the dura, and good anesthesia (14) are all
important. However, the bridging vein also chains the brain to
the dura, limiting the distance between them, even under
retraction of the brain. The “denude technique” makes it
possible to obtain a wider surgical corridor without sacrificing
the superficial Sylvian vein and its tributaries. The results of
our technique was satisfactory.
Impairment of Venous Outflow after Sylvian Fissure Dissection
Although sacrificing the superficial Sylvian vein and its tributaries
may cause venous congestion, hemorrhage, and edema, the
rarity of the clinical complications caused by venous sacrifice may
allow surgeons to sacrifice the superficial Sylvian veins (1, 13, 15,
19). Dean et al. (2) investigated the incidence of postoperative

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angiographic changes in the superficial Sylvian vein and cerebral
edema on postoperative CT after clipping of middle cerebral
artery aneurysms. Brain edema was present in 47%, and the
opacification of the superficial Sylvian veins were severely
affected in 11% of the patients. In cases with severely
affected veins, postoperative CT detected cerebral edema with
a mean area of 10.8 cm2 (3.7 cm in diameter, assuming the
shape of the edema is circular). The severity of angiographic
alteration of the superficial Sylvian vein correlated with the area
of edema. This report clarified the consequence of damaging
the venous outflow and the importance of venous preservation.
Unfortunately, Dean et al. did not mention whether they had
sacrificed the superficial Sylvian vein and did not describe the
clinical outcomes of these cases. Because we did not routinely
perform postoperative angiography, the patency of the vein
could not be determined. It is true that an anatomically
preserved vein may thrombose, however there is no possibility
that a sacrificed vein is patent.
Because the superficial Sylvian veins run along the inferolateral
frontal lobe where the verbal area resides in the dominant
hemisphere, venous congestion in this area may cause verbal
disturbances that markedly reduce quality of life. Even in the
nondominant hemisphere, disconnection of the Sylvian venous
outflow may provoke neurological decline, including facial palsy
and seizures (15). Furthermore, venous compromise makes the
brain more susceptible to retraction, resulting in increased
frequency of contusion (9, 10). Most of the brain edema after
venous sacrifice appears to be overlooked because it is clinically
asymptomatic.
Choice of the Approach: Distal or Proximal transsylvian Approach
The selection of the surgical approach, either the proximal or
distal transsylvian approach, is usually made according to the
preference of the surgeon. We prefer the distal transsylvian
approach because it is easier, less retraction is needed, and a
wider surgical corridor to approach the lesion is obtained when
compared with the proximal approach. The most difficult part of
the proximal approach is to dissect the proximal Sylvian
fissure from the outside. Using the “paperknife technique” in a
distal-to-proximal or inside-to-outside fashion facilitates dissec-
tion of the proximal fissure.
A cadaveric study showed that opening the lateral Sylvian fissure
increases the exposure of the structures and the surgical corridor
and reduces the retraction of the frontal lobe when approaching
the arteries in the basal cistern when compared with opening the
proximal Sylvian fissure only (4). Although this result cannot be
directly applied to the real operative setting, we believe that
the results are reasonable, and we usually split the Sylvian
fissure widely. Although the direction of Sylvian dissection is
different between the proximal and distal approach, the idea of
the “microvascular Sylvian fissure” is also applicable to
preserve veins in the proximal approach. The “denude
technique” can be employed in this approach as well.
Alternative or Additional Technique to Preserve the Veins
Few other techniques to preserve the superficial Sylvian veins
have been reported. Transferring the sphenoparietal sinus by
freeing the dura from the sphenoid bone (5, 12) may be useful in
combination with our technique. However, this technique cannot
be used in cases in which the frontal superficial Sylvian vein
drains directly into the cavernous sinus. The dural closure
becomes difficult after cutting the dura along the sphenoid ridge.
As our results showed, Sylvian dissection without venous sacri-
fice is usually the most difficult in cases with a single superficial
Sylvian vein receiving blood from both the frontal and temporal
lobes because tributaries from both lobes may interfere with the
dissection. The Sylvian fissure is entered through the space
between the tributaries. Every tributary is dissected from the
brain to mobilize it. If the surgical corridor is not large enough to
approach a lesion after the denude technique is completed,
another approach, such as a contralateral approach or inter-
hemispheric approach, should be considered.
CONCLUSION
Preserving the veins is of great importance in modern neuro-
surgery to decrease postoperative morbidity. The traditional
Sylvian split that mechanically sacrifices the frontal superficial
Sylvian veins and its tributaries should be reconsidered. With the
use of the technique described in the present report, the Sylvian
fissure is divided safely, and a wide surgical corridor is achieved.

pterional-transsylvian approach: an analytical Neurosurgery 56:172-177; discussion 172-177,

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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received: 6 June 2015; accepted: 20 July 2015
Citation: World Neurosurg. (2015) 84, 6:2043-2052.
http://dx.doi.org/10.1016/j.wneu.2015.07.050
Journal homepage: www.WORLDNEUROSURGERY.org
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