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DOI: 10.1055/s-0042-1750188
Microsurgical Anatomy of Middle Cerebral Artery in Northwest Indian Population: A Cadaveric Brain Dissection Study
- Abstract
- Introduction
- Materials and Methods
- Observations and Results
- Discussion
- Conclusion
- References
Abstract
The introduction of cadaveric dissection of cerebral vasculature as a part of the neurosurgical training module would help the neurosurgical residents to understand the complex neuroanatomy of the brain vasculature and help gain confdence during the surgical procedure.To the best of our knowledge microsurgical anatomical studies of theMCA have not been done among the Northwest Indian population. Anatomical variations of MCA that have not been described before may come in as a surprise during any surgical intervention. Hence, we intend to record the anatomical variations of the MCA anatomy and its implications in contemporary vascular surgery and neurosurgical practice. The objective of this work was to study and compare the microsurgical anatomy and variations of MCA in Northwest Indian cadavers with the available literature.
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Introduction
The initial descriptions of cerebral vasculature were given by anatomists, such as Thomas Willis in the 16th century, who laid the foundation for neurosurgeons, neurologists, and neuroradiologists. The middle cerebral artery (MCA) is one of the branches of the circle of Willis that supplies a significant part of the cerebral hemispheres. Saccular aneurysms commonly arise from MCA and most of the arteriovenous malformations (AVMs) receive arterial supply from MCA. Branches of MCA are encountered by neurosurgeons in most supratentorial approaches. Hence, a thorough knowledge of microsurgical neuroanatomy with respect to its branching and variation patterns would help the treating neurosurgeon in surgical or endovascular management. The introduction of cadaveric dissection of cerebral vasculature as a part of the neurosurgical training module would help the neurosurgical residents to understand the complex neuroanatomy of the brain vasculature and help gain confidence during the surgical procedure.[1] [2] [3] [4]
To the best of our knowledge microsurgical anatomical studies of the MCA have not been done among the Northwest Indian population. Anatomical variations of MCA that have not been described before may come in as a surprise during any surgical intervention. Hence, we intend to record the anatomical variations of the MCA anatomy and its implications in contemporary vascular surgery and neurosurgical practice. The objective of this work was to study and compare the microsurgical anatomy and variations of MCA in Northwest Indian cadavers with the available literature.
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Materials and Methods
Fifteen cadaveric brains (5 cadavers and 10 retrieved formalin-preserved brains), that is, 30 MCA vessels were dissected using an operating microscope (Carl Zeiss) with an optical zoom of 3× and 20 × . The Sylvian fissure was split from lateral to medial, origin of MCA identified, and M1 segment (MCA segment from the origin to genu)[5] was studied with respect to the outer diameter, length, and the pattern of division of the main trunk and classified into, type 1, bifurcation; type 2, single trunk; type 3, trifurcation; and type 4, others ([Table 1]). The outer diameter of each trunk and their respective lengths were measured. The early cortical branches, which arise before the actual division of the main trunk, were studied with respect to point of origin from MCA, outer diameter, the pattern of origin (single branch/stem), and area of supply. The lenticulostriate artery defined as the branches arising from the medial and inferior aspect of M1 segment and directed toward anterior perforated substance (APS) were identified under high magnification, their number, pattern of origin, and distance of origin from MCA were studied, and classified into medial, intermediate, and lateral groups. At the limen insula where the MCA forms genu and continues into the Sylvian fissure is referred to as M2 segment (insular segment) up to the circular sulcus of the insula. M2 was studied with respect to the outer diameter, length, pattern of division, and the origin of cortical branches, similarly opercular segment (M3) and cortical segment (M4 and M5) were studied. Schematic hand drawings of the MCA segments were done for each vessel, relevant photographs taken, and the cortical branches were studied up to the cerebral convexity. The measurements were taken with the help of digital microcalipers and the measurements were compared and confirmed by two independent observers.
Abbreviation: MCA, middle cerebral artery.
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Observations and Results
The MCA originates at the bifurcation of internal cerebral artery (ICA), lateral to the optic chiasm, and courses laterally and slightly forward under the APS to reach the medial end of the Sylvian fissure. At this point, the artery turns, crosses over the limen insula, and enters the insular area. The main division of the MCA is usually seen before or at the limen insula. The secondary trunks resulting from this division will course over the surface of the insular cortex, giving rise to cortical branches while turning over the opercular cleft, these cortical branches spread out over the cerebral convexity.
Main Trunk
The length of the main trunk (M1) from origin to genu, was commonly 16 ± 3 mm, with no significant difference between either side. The shortest length of M1 measured was 8 mm in one cadaver on one side and the longest being 23 mm in one cadaver with type 3 division. Outer diameter was 3 ± 0.5 mm bilaterally.
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Early Branches
The cortical branches arising from the main trunk proximal to the division of M1 segment are described as early branches. Among the early branches studied 58% were destined to the temporal lobe and 29% to the frontal lobe. The temporopolar artery and the anterior temporal artery (ATA), which supply the temporal pole and the anterior portion of the lateral aspect of the temporal lobe, respectively, were the early branches commonly seen ([Table 2]). The distance between MCA origin and first early branch origin was 4 ± 2 mm on the right and 4.4 ± 2.5 mm on the left side. The temporopolar artery, frequently, the first cortical branch seen when the Sylvian fissure is dissected, was seen in 28 of hemispheres studied (98%). In the two hemispheres, where it was absent, the vascular supply to the temporal pole was provided by the collateral branches of the ATA. The uncal artery was seen in five hemispheres.
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Perforating Branches
The medial group was seen in 20 of 30 hemispheres. Predominantly, it arose directly from the M1 segment as 2 to 5 single twigs, at a distance of 2 to 4 mm from the MCA origin, and pursued a direct course almost 90 degrees to the APS ([Fig. 1A and B]). The intermediate group, most consistently seen (26 out of 30 hemispheres), originated from the M1 trunk as a single stem artery which later divided into multiple branches (2–3 branches), at a distance of 5 to 7 mm from the MCA origin ([Fig. 2]) and took an oblique course to the APS. The lateral group originated from either the main trunk or secondary trunks (mostly superior trunk), was seen in 22 out of 30 hemispheres, at a distance of 7 to 15 mm from the MCA origin, and took an “S” shape course to the APS.
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Main Division and Secondary Trunks
The main trunk of the MCA was classified based on its pattern of division into secondary branches ([Table 1]). The trunks arising from the division of MCA's main trunk were called “Secondary trunks.” Bifurcation (type 1): the most common type, seen in 24 of 30 hemispheres (80%) where the main trunk is divided into a superior trunk (frontal) and inferior trunk (temporal) ([Fig. 3A and B]). Single trunk (type 2) in 3 out of 30 hemispheres (10%), the cortical branches arose as collateral vessels from a single trunk that ended in the angular artery ([Fig. 4A and B]). Trifurcation (type 3) in 3 out of 30 hemispheres (10%), the main trunk divided into superior, middle, and inferior trunks ([Fig. 5A and B]). Type 4 (others), > 3 trunks—none in this study. Among the 24 cases in type 1, 5 hemispheres had equal dominance of trunks (20.8%), 12 had inferior trunk dominance (50%) ([Fig. 6A and B]), and 7 had superior trunk dominance (29.1%). The length, outer diameter, and division pattern and number of cortical branches from secondary trunks were studied ([Table 2]).
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Cortical Branches
The distribution of the cortical branches of the MCA has been extensively described. In this study, 10 cortical branches were studied near their origin from M1 and M2 segments of the MCA.[6] The cortical branches studied were temporopolar, anterior, middle, posterior temporal, angular, orbitofrontal, precentral, central, anterior parietal, and posterior parietal arteries. The pattern of origin of cortical branches from M2 was studied ([Table 3]). The outer diameter of the cortical branches at their origin and also the distance of origin from the MCA origin was measured ([Table 4]). The temporopolar, anterior temporal, and orbitofrontal arteries originated relatively close to MCA origin and the angular artery, posterior parietal, and posterior temporal arise distally in the posterior half of the insular area. In type 1, the cortical branches from the secondary trunks were as follows—the superior trunk gave rise to orbitofrontal, prefrontal, precentral, and central arteries, and the inferior trunk gave rise to anterior temporal, middle temporal, posterior temporal, and the angular arteries while the anterior and posterior parietal was seen to arise from the dominant trunk. In type 3, the superior trunk gave rise to the orbitofrontal, prefrontal, precentral, and central artery. The middle trunk gave rise to anterior parietal, posterior parietal, and angular artery, and the inferior trunk gave rise to the anterior, middle, and posterior temporal arteries. The unusual origin of cortical arteries was not observed.
Abbreviations: IT, inferior trunk; MT, middle trunk; ST, superior trunk.
Abbreviations: ICA, internal cerebral artery; MCA, middle cerebral artery.
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Stem Arteries
The temporopolar artery and the ATA were the most common vessels arising from a common stem, seen in 90% of hemispheres. Less frequent associations, the anterior temporal, middle temporal, and posterior temporal arteries in 5%; anterior temporal and posterior temporal arteries in 5%; posterior temporal, posterior parietal, and central arteries in 2%; central, anterior parietal, and precentral arteries in 4%; precentral, central, and orbitofrontal arteries in 3%; posterior parietal and central arteries in 3%; and orbitofrontal and central arteries in 1%. While commonly 2-stem pattern was observed in the frontal lobe, temporal lobe had 4-stem pattern, and the parietal lobe had 2-stem pattern ([Table 5]).
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Cortical Arteries
The cortical arteries arose from the stem arteries and supplied the individual cortical areas. Generally, one or less commonly, two cortical arteries passed to each of the 12 cortical areas, the smallest cortical arteries arose at the anterior end of the Sylvian fissure and the largest ones at the posterior limits of the fissure. The cortical branches to the frontal, anterior temporal, and anterior parietal areas were smaller than those supplying the posterior parietal, posterior temporal, temporo-occipital, and angular areas. The smallest arteries supplied the orbitofrontal and temporopolar areas, and the largest ones supplied the temporo-occipital and the angular areas.
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Discussion
The main trunk of MCA takes origin from ICA(B), lateral to the optic chiasm, and travels toward the medial end of the Sylvian fissure below the APS.[5] [7] [8] [9] Bifurcation was seen in 80% cases in our study similar to other studies,[7] [9] [10] single trunk in 6%, and trifurcation in 10%. In a North Indian study,[11] bifurcation was seen in 64%, single trunk in 6%, and trifurcation in 29%. In a South Indian study,[12] [13] bifurcation was seen in 90%, trifurcation in 10%, and no single trunk. The mean distance between the origin of the MCA and its main division was 18 ± 2.4 mm (right hemisphere) and 18 ± 2.2 mm (left hemisphere), with no significant difference between the two. In other studies, the mean length of M1 was measured to be 15 ± 1.3 mm,[9] 14 to 16 mm,[14] and 20 mm.[12] The diameter of M1 at origin was 2 to 3.5 mm with no significant difference between both sides, in our study. In other studies, the mean diameter of M1 was 3 ± 0.1 mm[9] and 2 to 4 mm.[12]
The most proximal division (early bifurcation) was seen at 8 mm and the most distal division (late bifurcation) at 25 mm. The more proximal the division, the more likely that the perforating branches would arise from the secondary trunks.[5] [7] [9] Most saccular aneurysms of the MCA are located near the main division of the artery.[15] [16] Thus, while dissecting the aneurysm, the surgeon should be aware of the possibility of finding perforating branches that run in a recurrent course from one of the secondary trunks toward the APS.
Perforators arose M1 in 79%, 15.3% from M2 (superior: 8.5%, middle: 0.9%, inferior: 5.9%), and the remaining 5.7% originated from early branches (early temporal branches, 5.3%, early frontal branches, 0.4%),[9] from M1 79.6% and from M2 in 20.3%.[11] [17] In our study, 90% perforating arteries were seen to arise before bifurcation and 10% from secondary trunks (superior trunk 8%, inferior trunk 2%) and 3% from early branches. The number of perforators range from 3 to 15 in number.[14] [18] In our study, the number varied from 3 to 12. Four patterns of origin of perforators were seen,[14] the most frequent being a single stem artery that then divides into many branches (seen in 40%), two large parallel arteries that immediately divide into numerous branches (30%), and numerous small twigs which arise directly from the inferio-medial side of M1 (30%). The perforators can be divided into medial, intermediate, and lateral groups.[14] The most consistent of the groups was the intermediate group in the current study, seen in 93.3% with the most common pattern being a single large stem which divided early into multiple small arteries in its course to APS. The medial group was seen in 80%, commonly arose as 2 to 4 parallel arteries at an obtuse angle from the parent artery (the angle was however not measured). The lateral group was seen in 88.7%, and arose as multiple small twigs at an acute angle from the parent vessel and took an S shape course to APS. Perforators originated from MCA origin at a distance of 1 ± 0.2 mm (medial group), 4 ± 1 mm (intermediate group), and 10 ± 2 mm (lateral group).
The knowledge of anatomy and the possibility of an early branch is important for the surgical aspect, which would give a pseudo-bifurcation appearance and result in misinterpretation of true bifurcation and branches. The most common early branch seen in our study was the temporopolar artery (73.4%) as compared with 92% in other studies.[9] The uncal artery was seen to arise as an early branch in 5 cases (16%) in our study. It is reported that the uncal artery takes origin mostly from the ICA.[14] The most common vessels arising as a common stem pattern in our study were the temporopolar and ATA (43.3%), similar to other studies.[7] [9]
The MCA is one of the most common sites of saccular aneurysms,[15] [16] [19] [20] mostly located on the distal part of the M1 segment at the bifurcation of MCA. Saccular aneurysms rarely arise distal to the proximal portion of the M2 segment. Traumatic aneurysms or bacterial aneurysms are located most commonly in the M4 segment.[21] [22] [23] The majority of intracranial AVMs receive part of their blood supply from branches of the MCA.[24] Clinical syndromes associated with occlusion of the individual cortical branches of MCA are rare.[25] [26] [27] [28] Embolisms frequently cause occlusion of the MCA than thrombosis.[26] [27] [28] Extracranial (EC)-MCA anastomosis is a treatment option for distal MCA occlusions and moyamoya disease.[29] The external diameter of 1 mm is the minimum requirement for long-term anastomosis patency.[30] In the temporal zone, an artery with a diameter greater than 1.0 mm was present in 70% of hemispheres. Chater et al[30] recommended small craniotomy for exposing the cortical branches of the MCA and that it be centered 6 cm above the external auditory canal. The distance between the ear canal and the posterior end of the Sylvian fissure was recorded to be 6.6 cm in length,[9] similar to our study. The outer diameter of the vessels in the insular area was larger than 1 mm, and in the case of the secondary trunks, it was usually greater than 2 ± 0.2 mm in our study, similar to other studies.[7] [8] [9] The angular artery, the vessel most appropriate for EC-ICA anastomosis, was the largest among cortical branches, 1.4 ± 1 mm in our study, and 1.5 ± 0.2 mm in another study.[7] Anomalies of the MCA are less common.[11] [31] [32] The anomalies reported are duplication and accessory MCA.[12] [17] [19] Aneurysm of the accessory MCA has been reported.[33] [34] There were no anomalies observed in our study.
Several authors have used different contrast media, that helps in delineating vascular microanatomy better.[5] [35] [36] In the current study, though initially contrast media (coloured silicon granules [CSD granules]) was injected, due to technical reasons, the uptake was not acceptable. Hence, most brains dissected were without prior contrast administration.
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Conclusion
A good knowledge of microsurgical anatomy of MCA and its variations is a prerequisite for a neurosurgeon operating in this area, the frequent mistake of misinterpreting early branch for division of main branch, can be avoided with knowledge of its occurrence of the same. Cadaveric microsurgical dissection and practice if included as an integral part of neurosurgical training, as in our institute, will improve the neuroanatomical knowledge and understanding during live surgical or endovascular procedures. All neurosurgical training institutes should have a fully equipped microsurgical cadaveric laboratory and microsurgical dissection should be included part of neurosurgical training curriculum.
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Conflict of Interest
None declared.
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References
- 1 Aboud E, Al-Mefty O, Yaşargil MG. New laboratory model for neurosurgical training that simulates live surgery. J Neurosurg 2002; 97 (06) 1367-1372
- 2 Gilbody J, Prasthofer AW, Ho K, Costa ML. The use and effectiveness of cadaveric workshops in higher surgical training: a systematic review. Ann R Coll Surg Engl 2011; 93 (05) 347-352
- 3 Gnanakumar S, Kostusiak M, Budohoski KP. et al. Effectiveness of cadaveric simulation in neurosurgical training: a review of the literature. World Neurosurg 2018; 118: 88-96
- 4 James HK, Chapman AW, Pattison GTR, Griffin DR, Fisher JD. Systematic review of the current status of cadaveric simulation for surgical training. Br J Surg 2019; 106 (13) 1726-1734
- 5 Rhoton Jr AL. The supratentorial arteries. Neurosurgery 2002; 51 (4, suppl) S53-S120
- 6 Vander Eecken HM. Morphological significance of leptomeningeal anastomoses confined to the territory of cerebral arteries [in French]. Acta Neurol Psychiatr Belg 1954; 54 (07) 525-532
- 7 Gibo H, Carver CC, Rhoton Jr AL, Lenkey C, Mitchell RJ. Microsurgical anatomy of the middle cerebral artery. J Neurosurg 1981; 54 (02) 151-169
- 8 Yasargil MG. Intracranial arteries. In: Microneurosurgery. New York: Thieme; 1987: 54-164
- 9 Umansky F, Juarez SM, Dujovny M. et al. Microsurgical anatomy of the proximal segments of the middle cerebral artery. J Neurosurg 1984; 61 (03) 458-467
- 10 Ring BA. Middle cerebral artery: anatomical and radio-graphic study. Acta Radiol 1962; 57: 289-300
- 11 Jain KK. Some observations on the anatomy of the middle cerebral artery. Can J Surg 1964; 7: 134-139
- 12 Pai SB, Varma RG, Kulkarni RN. Microsurgical anatomy of the middle cerebral artery. Neurol India 2005; 53 (02) 186-190
- 13 Gunnal SA, Farooqui MS, Wabale RN. Study of middle cerebral artery in human cadaveric brain. Ann Indian Acad Neurol 2019; 22 (02) 187-194
- 14 Yasargil MG, Fox JL. The microsurgical approach to intracranial aneurysms. Surg Neurol 1975; 3 (01) 7-14
- 15 Locksley HB. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. Based on 6368 cases in the cooperative study. J Neurosurg 1966; 25 (02) 219-239
- 16 Rhoton Jr AL. Anatomy of saccular aneurysms. Surg Neurol 1980; 14 (01) 59-66
- 17 Grand W. Microsurgical anatomy of the proximal middle cerebral artery and the internal carotid artery bifurcation. Neurosurgery 1980; 7 (03) 215-218
- 18 Rosner SS, Rhoton Jr AL, Ono M, Barry M. Microsurgical anatomy of the anterior perforating arteries. J Neurosurg 1984; 61 (03) 468-485
- 19 Crompton MR. The pathology of ruptured middle-cerebral aneurysms with special reference to the differences between the sexes. Lancet 1962; 2 (7253): 421-425
- 20 Perret G, Nishioka H. Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section VI. Arteriovenous malformations. An analysis of 545 cases of cranio-cerebral arteriovenous malformations and fistulae reported to the cooperative study. J Neurosurg 1966; 25 (04) 467-490
- 21 Asari S, Nakamura S, Yamada O, Beck H, Sugatani H. Traumatic aneurysm of peripheral cerebral arteries. Report of two cases. J Neurosurg 1977; 46 (06) 795-803
- 22 Bohmfalk GL, Story JL, Wissinger JP, Brown Jr WE. Bacterial intracranial aneurysm. J Neurosurg 1978; 48 (03) 369-382
- 23 Fleischer AS, Patton JM, Tindall GT. Cerebral aneurysms of traumatic origin. Surg Neurol 1975; 4 (02) 233-239
- 24 Lawton MT, Rutledge WC, Kim H. et al. Brain arteriovenous malformations. Nat Rev Dis Primers 2015; 1: 15008
- 25 Waddington MM, Ring BA. Syndromes of occlusions of middle cerebral artery branches. Brain 1968; 91 (04) 685-696
- 26 Fisher CM. Clinical syndromes in cerebral thrombosis, hypertensive hemorrhage, and ruptured saccular aneurysm. Clin Neurosurg 1975; 22: 117-147
- 27 Lascelles RG, Burrows EH. Occlusion of the middle cerebral artery. Brain 1965; 88: 85-96
- 28 Lhermitte F, Gautier JC, Derouesné C. Nature of occlusions of the middle cerebral artery. Neurology 1970; 20 (01) 82-88
- 29 Cheikh A, Yasuhiro Y, Kasinathan S, Kawase T, Takao T, Kato Y. Superficial temporal artery: middle cerebral artery bypass, our series of 20 cases, surgical technique and indications with illustrative cases. Asian J Neurosurg 2019; 14 (03) 670-677
- 30 Chater N, Spetzler R, Tonnemacher K, Wilson CB. Microvascular bypass surgery. Part 1: anatomical studies. J Neurosurg 1976; 44 (06) 712-714
- 31 Teal JS, Rumbaugh CL, Bergeron RT, Segall HD. Anomalies of the middle cerebral artery: accessory artery, duplication, and early bifurcation. Am J Roentgenol Radium Ther Nucl Med 1973; 118 (03) 567-575
- 32 Uchiyama N. Anomalies of the middle cerebral artery. Neurol Med Chir (Tokyo) 2017; 57 (06) 261-266
- 33 Handa J, Matsuda M, Okamoto K, Kidooka M. Association between accessory middle artery and cerebral aneurysm. Report of two cases. Acta Neurochir (Wien) 1982; 64 (1-2): 151-157
- 34 Waga S, Kojima T, Morooka Y, Sakakura M. Aneurysm of the accessory middle cerebral artery. Surg Neurol 1977; 8 (05) 359-360
- 35 Limpastan K, Vaniyapong T, Watcharasaksilp W, Norasetthada T. Silicone injected cadaveric head for neurosurgical dissection: prepared from defrosted cadaver. Asian J Neurosurg 2013; 8 (02) 90-92
- 36 Soubam P, Mishra S, Suri A. et al. Standardization of the technique of silicon injection of human cadaveric heads for opacification of cerebral vasculature in Indian conditions. Neurol India 2018; 66 (02) 439-443
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Publication History
Article published online:
16 July 2024
© 2024. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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References
- 1 Aboud E, Al-Mefty O, Yaşargil MG. New laboratory model for neurosurgical training that simulates live surgery. J Neurosurg 2002; 97 (06) 1367-1372
- 2 Gilbody J, Prasthofer AW, Ho K, Costa ML. The use and effectiveness of cadaveric workshops in higher surgical training: a systematic review. Ann R Coll Surg Engl 2011; 93 (05) 347-352
- 3 Gnanakumar S, Kostusiak M, Budohoski KP. et al. Effectiveness of cadaveric simulation in neurosurgical training: a review of the literature. World Neurosurg 2018; 118: 88-96
- 4 James HK, Chapman AW, Pattison GTR, Griffin DR, Fisher JD. Systematic review of the current status of cadaveric simulation for surgical training. Br J Surg 2019; 106 (13) 1726-1734
- 5 Rhoton Jr AL. The supratentorial arteries. Neurosurgery 2002; 51 (4, suppl) S53-S120
- 6 Vander Eecken HM. Morphological significance of leptomeningeal anastomoses confined to the territory of cerebral arteries [in French]. Acta Neurol Psychiatr Belg 1954; 54 (07) 525-532
- 7 Gibo H, Carver CC, Rhoton Jr AL, Lenkey C, Mitchell RJ. Microsurgical anatomy of the middle cerebral artery. J Neurosurg 1981; 54 (02) 151-169
- 8 Yasargil MG. Intracranial arteries. In: Microneurosurgery. New York: Thieme; 1987: 54-164
- 9 Umansky F, Juarez SM, Dujovny M. et al. Microsurgical anatomy of the proximal segments of the middle cerebral artery. J Neurosurg 1984; 61 (03) 458-467
- 10 Ring BA. Middle cerebral artery: anatomical and radio-graphic study. Acta Radiol 1962; 57: 289-300
- 11 Jain KK. Some observations on the anatomy of the middle cerebral artery. Can J Surg 1964; 7: 134-139
- 12 Pai SB, Varma RG, Kulkarni RN. Microsurgical anatomy of the middle cerebral artery. Neurol India 2005; 53 (02) 186-190
- 13 Gunnal SA, Farooqui MS, Wabale RN. Study of middle cerebral artery in human cadaveric brain. Ann Indian Acad Neurol 2019; 22 (02) 187-194
- 14 Yasargil MG, Fox JL. The microsurgical approach to intracranial aneurysms. Surg Neurol 1975; 3 (01) 7-14
- 15 Locksley HB. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. Based on 6368 cases in the cooperative study. J Neurosurg 1966; 25 (02) 219-239
- 16 Rhoton Jr AL. Anatomy of saccular aneurysms. Surg Neurol 1980; 14 (01) 59-66
- 17 Grand W. Microsurgical anatomy of the proximal middle cerebral artery and the internal carotid artery bifurcation. Neurosurgery 1980; 7 (03) 215-218
- 18 Rosner SS, Rhoton Jr AL, Ono M, Barry M. Microsurgical anatomy of the anterior perforating arteries. J Neurosurg 1984; 61 (03) 468-485
- 19 Crompton MR. The pathology of ruptured middle-cerebral aneurysms with special reference to the differences between the sexes. Lancet 1962; 2 (7253): 421-425
- 20 Perret G, Nishioka H. Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section VI. Arteriovenous malformations. An analysis of 545 cases of cranio-cerebral arteriovenous malformations and fistulae reported to the cooperative study. J Neurosurg 1966; 25 (04) 467-490
- 21 Asari S, Nakamura S, Yamada O, Beck H, Sugatani H. Traumatic aneurysm of peripheral cerebral arteries. Report of two cases. J Neurosurg 1977; 46 (06) 795-803
- 22 Bohmfalk GL, Story JL, Wissinger JP, Brown Jr WE. Bacterial intracranial aneurysm. J Neurosurg 1978; 48 (03) 369-382
- 23 Fleischer AS, Patton JM, Tindall GT. Cerebral aneurysms of traumatic origin. Surg Neurol 1975; 4 (02) 233-239
- 24 Lawton MT, Rutledge WC, Kim H. et al. Brain arteriovenous malformations. Nat Rev Dis Primers 2015; 1: 15008
- 25 Waddington MM, Ring BA. Syndromes of occlusions of middle cerebral artery branches. Brain 1968; 91 (04) 685-696
- 26 Fisher CM. Clinical syndromes in cerebral thrombosis, hypertensive hemorrhage, and ruptured saccular aneurysm. Clin Neurosurg 1975; 22: 117-147
- 27 Lascelles RG, Burrows EH. Occlusion of the middle cerebral artery. Brain 1965; 88: 85-96
- 28 Lhermitte F, Gautier JC, Derouesné C. Nature of occlusions of the middle cerebral artery. Neurology 1970; 20 (01) 82-88
- 29 Cheikh A, Yasuhiro Y, Kasinathan S, Kawase T, Takao T, Kato Y. Superficial temporal artery: middle cerebral artery bypass, our series of 20 cases, surgical technique and indications with illustrative cases. Asian J Neurosurg 2019; 14 (03) 670-677
- 30 Chater N, Spetzler R, Tonnemacher K, Wilson CB. Microvascular bypass surgery. Part 1: anatomical studies. J Neurosurg 1976; 44 (06) 712-714
- 31 Teal JS, Rumbaugh CL, Bergeron RT, Segall HD. Anomalies of the middle cerebral artery: accessory artery, duplication, and early bifurcation. Am J Roentgenol Radium Ther Nucl Med 1973; 118 (03) 567-575
- 32 Uchiyama N. Anomalies of the middle cerebral artery. Neurol Med Chir (Tokyo) 2017; 57 (06) 261-266
- 33 Handa J, Matsuda M, Okamoto K, Kidooka M. Association between accessory middle artery and cerebral aneurysm. Report of two cases. Acta Neurochir (Wien) 1982; 64 (1-2): 151-157
- 34 Waga S, Kojima T, Morooka Y, Sakakura M. Aneurysm of the accessory middle cerebral artery. Surg Neurol 1977; 8 (05) 359-360
- 35 Limpastan K, Vaniyapong T, Watcharasaksilp W, Norasetthada T. Silicone injected cadaveric head for neurosurgical dissection: prepared from defrosted cadaver. Asian J Neurosurg 2013; 8 (02) 90-92
- 36 Soubam P, Mishra S, Suri A. et al. Standardization of the technique of silicon injection of human cadaveric heads for opacification of cerebral vasculature in Indian conditions. Neurol India 2018; 66 (02) 439-443