Journal of Neurosurgery. 2026;145(4):1199-1207
The intraoccipital sulcus may provide a useful route to the ventricular atrium, but following a natural sulcus does not eliminate white matter injury. Anastasopoulos and colleagues map a roof-directed corridor whose potential advantages remain anatomical rather than clinically demonstrated. Their findings inform approach selection without establishing superior safety or preservation of visual function.
Study and key findings
The investigators examined 20 adult cadaveric hemispheres from 10 donors, supplemented by MRI assessment of 20 Human Connectome Project subjects and another 25 healthy individuals.
The anterior approximately 1.2-cm sulcal segment aligned with the atrial roof; posterior trajectories instead led toward the occipital horn. The mean MRI distance from the sulcal fundus to the atrium was 1.90 ± 0.48 cm. These descriptive measurements are not patient-specific safety margins.
Although the medial, roof-directed trajectory offers a potentially favorable relationship to lateral-wall optic radiations, the corridor disrupts the vertical occipital fasciculus and crosses the posterior sagittal stratum and tapetum. It is therefore not a white matter-free route.
Interpretation and limitations
The practical question is whether the anterior intraoccipital sulcus provides suitable exposure for a particular atrial lesion. Anterior and posterior sulcal segments are not interchangeable, and lesions extending farther anteriorly may require an unfavorable working distance. A plausible editorial implication is to weigh target geometry and intervening fiber anatomy together, rather than select the approach solely from a recognizable surface landmark.
No operative series, postoperative visual outcomes or clinical comparison with alternative approaches was included. Cadaveric tissue and illustrative template-space tractography cannot establish individual functional safety. Manual MRI measurements also lacked demonstrated interobserver reliability.
Clinical takeaway
The anterior intraoccipital sulcus deserves consideration as an anatomical option for atrial access. Its contribution is a clearer understanding of trajectory and white matter costs, not proof of a safer operation. Clinical validation remains necessary before anatomical feasibility can be translated into claims of neurological benefit.
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