The putamen, combined with the globus pallidus forms the lentiform nucleus; and with the caudate nucleus, it shapes the striatum which is a subcortical structure that forms the basal ganglia. The putamen is involved in learning and motor control, including speech articulation, and language functions, reward, cognitive functioning, and addiction. Research has noted putaminal dysfunctions in various motor and cognitive dysfunctions, namely Parkinson disease, Huntington disease, Alzheimer disease, depression, obsessive-compulsive disorder, Wilson disease, and autism.
The basal ganglia are a group of deep brain nuclei that divide into the putamen, caudate nucleus, nucleus accumbens, and globus pallidus. The putamen, caudate, and nucleus accumbens form striatum. Different parts of the striatum receive afferent input from different cortical regions and project its efferent output to the cortex through the thalamus. Anterior putamen connects with the associative regions in the cortex, and the posterior portion connects with the primary motor cortex and the supplementary motor area.
The striatum plays a significant role in various brain functions, including motor control and learning, language, reward, cognitive functioning, and addiction through the functional cortico-striato-thalamocortical neural pathways. Traditionally, the basal ganglia structures are known for their motor functions. However, it is well studied now that the basal ganglia are not only involved in purely motor functions, but also they are associated with more complex goal-directed behaviors, including emotion, motivation, and cognition components to express a particular movement. Therefore a pathologic state (e.g., neurodegeneration, hemorrhage, etc.) in the striatum can lead to a broad range of clinical manifestation from motor dysfunction such as Parkinson disease to various psychiatric disorders.
The putamen is also involved in modulating the sensory as well as motor aspects of pain.
From cephalic to caudal, the primary three primitive brain vesicles differentiate to the prosencephalon (forebrain), mesencephalon (midbrain), and rhombencephalon (hindbrain). By the end of the fifth weeks of gestation, prosencephalon differentiates to the telencephalon (cerebral hemispheres) and the diencephalon. The telencephalon gives rise to the components of the basal ganglia which includes the globus pallidus, the caudate and the putamen.
The putamen receives its vascular supply from the perforating branches of the anterior cerebral artery (ACA) and middle cerebral artery (MCA), also known as the lenticulostriate arteries, with variations of the predominance of either ACA or MCA supply. Although the brain tissue with the highest metabolic rate lacks conventional lymphatic system responsible for cleansing waste, the brain parenchyma owns its specific lymphatic drainage pathways, which are composed of:
The putamen, as a portion of basal ganglia, has a similar drainage system as the whole brain with structural differences in perivascular spaces compared to the cerebral cortex.
The putamen, situated in the striatal/dorsal portion of the basal ganglia, functions in harmony with the cortex through a complex cortico-basal ganglia network to perform and produce complex behaviors. It is believed to be the cooperation between separate functional channels and integration across a function that directs a coordinated behavior to exhibit and also be modified based on external and internal stimuli. The three primary afferent input sources to the striatum are cerebral cortex, thalamus, and primarily dopaminergic cells of the brain stem. Accordingly, outputs from the striatum travel to the pallidum complex and the substantia nigra, pars reticulata, and pars compacta.
Volumetric changes of the putamen have linked to different neurologic and psychiatric disorders. Large imaging meta-analyses have been conducted to establish the physiologic variation of the putamen to make it comparable to its pathologic condition and determine its physiological state. It has proven in almost all studies that the volume of putamen declines in size in both genders by aging. However, the effect of gender and hemispherical asymmetry is still controversial.
The putamen, as a common structure affected by a hypertensive cerebral hemorrhage, elicits a large range of presentations based on the magnitude of the initial blood extravasation. Despite the controversy, surgical evacuation of the intracerebral hemorrhage is a mainstay therapeutic approach to decompress the mass effect and also, eliminate the cytotoxic edema resulting from the ischemia and the degraded blood products Current recommendations to remove putaminal bleed include large size hematoma with life-threatening herniation, especially in young aged patients. The other indication of removal of hematoma includes the presence of hemiparesis owing to the compression of the internal capsule from the hematoma that can be confirmed by the application of the MR tractography study. There are different surgical approaches chosen based on the hematoma size and position, patients hemodynamical stability, underlying etiology, resources availability, and the surgeon’s preference. For example, the putaminal hemorrhages associated with arteriovenous malformations make it a contraindication for endoscopic surgery. Therefore, it necessitates changing the operating method from endoscopic to microscopic approach. Traditionally, a craniotomy was the first-line surgical treatment; but due to its high mortality and morbidity rate, endoscopy, and most recently, navigation guided or stereotactic aspiration, has been applied into considerations.  Although less invasive, the efficiency of hematoma evacuation is still low in endoscopy surgery owing to obscure visualization and limited scope incomplete hemostasis. Therefore, a stainless-steel tube has been introduced to guide the endoscope during the evacuation procedure. Moreover, a standard technique of endoscopy, precise targeting of the lesions, non-eloquent assess with minimal brain retraction, and maintaining optimal hemostasis are critical factors to eliminate postoperative complications. Despite all the disagreements over the timing of surgery and appropriate surgical approach (craniotomy, stereotactic or endoscopic) for hematoma evacuation, the most important factor to keep in mind is fast decompression to control the intracranial pressure, not the complete evacuation.
The putamen is a common site for hypertensive bleed as well as infarction. The corkscrew pattern of lenticulostriate vessels (increases intraluminal pressure) as well as the formation of
Bilateral putaminal hemorrhages, though rare, can occur in cases of bleeding disorders, methanol intoxication, metastatic lesions, and amyloid angiopathies.
There can be a multispectral presentation in cases with small putaminal strokes, and these can categorize as follows :
There can be aphasia due to putaminal bleed in the dominant hemisphere whereas spatial and hemineglect occur in right putaminal bleeds. The presence of a conjugate eye deviation (CED) has been regarded as a poor prognostic marker in these bleeds.
The putamen correlates with a broad spectrum of movement disorders and psychiatric diseases. The most well-known movement disorder related to putamen is Parkinson’s disease, which is the result of dopamine depletion in posterior putamen and presented by rigidity, tremor, ataxia, and impairment of balance. Changes in putamen volume link to a large number of diseases. While some disorders increase the volume of putamen, including bipolar disorder, Tourette syndrome, attention-deficit-hyperactivity disorder, researchers have seen a decline in volume in major depressive disorder, Williams syndrome, autism, schizophrenia, and suicide attempters. Interestingly, obsessive-compulsive disorder (OCD) prevents putaminal volume loss associated with normal aging. It also has been documented that repetitive behaviors of OCD develop in the putaminal lesions. Other pathologic conditions linked to dysfunction of putamen include Huntington disease, Lewy body disorders, Alzheimer disease, Wilson disease, motor and cognitive impairment following putaminal hemorrhage, gait dysregulation following a stroke, and bilateral putaminal necrosis as a sequela of methanol toxicity.
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