Surgical anatomy of the insula

The insula is the only cortical part of the brain which is not visible on the surface of the hemisphere. This is due to the fact that it is totally covered by the fronto-parietal and temporal opercula. The insula has a triangular shape, and is separated from the opercula by the anterior, superior, and inferior periinsular sulci. The limen insulae is the antero-inferiorly located insular cortical surface which conjoins the inferior insular point, the anterior perforated surface, and the temporo-mesial surface. The insula is morphologically divided into two parts by the central insular sulcus. The anterior part of the insula bears 3 gyri: the anterior, middle, and posterior short insular gyri, separated by the anterior and precentral insular sulcus. The posterior part of the insula contains the anterior and posterior long insular gyri, separated by the postcentral insular sulcus. The vascular supply of the insula is mainly provided by the M2 segment of the middle cerebral artery, which constitutes a substantial obstacle to any open or stereotactic procedure aiming at the insular region. Histologically, the insula is a part of the paralimbic cortex, as it bears in its antero-inferior part an allo and mesocortical area. The insula is functionally involved in cardiac rhythm and arterial blood pressure control, as well as in viscero-motor control and in viscero-sensitive functions. There is considerable evidence for the involvement of the insula as a somesthetic area, including a major role in the processing of nociceptive inputs. Its possible role in some epilepsies may explain some failures of temporal lobe resection. Surgery of the insular lobe is a technical challenge, whose risks can be minimized by the use of intra-operative direct cerebral stimulation.