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Cingulate cortex

The cingulate cortex is a paired brain structure located on the medial surface of the cerebral hemispheres, forming a C-shaped convolution that wraps around the corpus callosum and constitutes a major component of the limbic system.^[1] It encompasses several subdivisions, including the anterior cingulate cortex (ACC), midcingulate cortex (MCC), and posterior cingulate cortex (PCC), each with distinct cytoarchitectonic features such as the agranular organization in the ACC and granular layer IV prominence in the PCC.^[1] The ACC, spanning Brodmann areas 24, 25, 32, and 33, is further divided into perigenual (involved in emotion) and dorsal (involved in cognition) regions, while the PCC includes areas 23, 29, 30, and 31, contributing to visuospatial processing.^[1] Functionally, the cingulate cortex integrates sensory, emotional, and cognitive information to facilitate adaptive behaviors, with the ACC playing a central role in emotion processing, autonomic regulation, and reward-based decision-making.^[1] For instance, the pregenual ACC activates in response to pleasant stimuli, linking reward signals from the orbitofrontal cortex to emotional awareness, whereas supracallosal regions respond to unpleasant cues, supporting emotional regulation through connections to the amygdala and insula.^[2] The MCC and dorsal ACC contribute to action-outcome learning and voluntary motor control via cingulate motor areas that connect to premotor cortices and the spinal cord, enabling reward-guided action selection.^[1]^[2] The PCC and adjacent retrosplenial cortex are implicated in memory formation and spatial navigation, providing contextual information to the hippocampus through the parahippocampal gyrus and parietal cortex to support episodic and autobiographical recall.^[1]^[2] Overall connectivity occurs via the cingulum bundle, which links the cingulate cortex to limbic structures like the hippocampus and entorhinal cortex as part of the Papez circuit, as well as to prefrontal and motor regions for executive function and movement.^[1] Blood supply is primarily from branches of the anterior cerebral artery, including the pericallosal and callosomarginal arteries.^[1]

Anatomy

Location and gross morphology

The cingulate cortex is situated on the medial surface of the cerebral hemispheres as part of the limbic lobe, forming a C-shaped fold that encircles the corpus callosum from the subcallosal area anteriorly to the isthmus posterior to the splenium.^[1] This structure wraps around the genu and body of the corpus callosum, extending continuously with the parahippocampal gyrus posteriorly, and is bordered by the frontal, parietal, temporal, and occipital lobes.^[1] Its gross morphology reflects an arched configuration, with the cingulate gyrus comprising the upper, convex portion and the cingulate sulcus defining the lower boundary.^[3] A variable paracingulate sulcus often parallels the cingulate sulcus superiorly, serving as a key landmark that may be absent, rudimentary, or prominent, influencing the overall depth and segmentation of the region.^[3] The cingulate cortex is separated from the corpus callosum inferiorly by the callosal sulcus and from the superior frontal gyrus superiorly by the cingulate sulcus, contributing to its distinct medial positioning.^[1] In neuroimaging, particularly magnetic resonance imaging (MRI), the cingulate cortex is visualized as a thin strip of gray matter closely apposed to and encircling the white matter of the corpus callosum, with variations in sulcal patterns evident on sagittal views.^[3] The cingulate cortex encompasses anterior and posterior regions, though detailed subdivisions are addressed elsewhere.^[1]

Subdivisions

The cingulate cortex is traditionally divided into three primary regions along its rostro-caudal axis: the anterior cingulate cortex (ACC), midcingulate cortex (MCC), and posterior cingulate cortex (PCC). These subdivisions are delineated based on anatomical landmarks and sulcal patterns, providing a framework for understanding its regional organization.^[1] The anterior cingulate cortex (ACC) extends from the subcallosal gyrus rostrally to the genu of the corpus callosum, encompassing the pregenual (pgACC) and subgenual (sgACC) portions. The pgACC lies anterior to the genu and is bordered superiorly by the cingulate sulcus, while the sgACC is located ventral to the rostrum of the corpus callosum. This region corresponds primarily to Brodmann areas 24, 25, 32, and 33.^[1]^[4] The midcingulate cortex (MCC) is positioned centrally, spanning the region around the anterior commissure and extending posteriorly to the point where the cingulate sulcus meets the marginal ramus of the cingulate sulcus. It includes both dorsal and ventral aspects and is often considered a transitional zone between the ACC and PCC, incorporating parts of Brodmann area 24.^[1]^[5] The posterior cingulate cortex (PCC) occupies the caudal extent, from the isthmus of the cingulate gyrus to the posterior aspect of the splenium of the corpus callosum, and includes the retrosplenial cortex (RSC) in its most posterior portion. The RSC, comprising Brodmann areas 29 and 30, is bounded posteriorly by the parieto-occipital sulcus. The PCC as a whole aligns with Brodmann areas 23 and 31.^[1]^[6] These subdivisions are primarily defined by sulcal patterns, including the cingulate sulcus that parallels the corpus callosum and separates the cingulate gyrus from the superior frontal gyrus, as well as the callosal sulcus inferiorly. Anteriorly, the ACC is delimited near the central sulcus indirectly through its relation to frontal lobe margins, while posteriorly, the PCC terminates at the parieto-occipital sulcus.^[1]^[5] Individual variability in cingulate morphology is notable, particularly in sulcal folding. The paracingulate sulcus, a parallel sulcus dorsal to the cingulate sulcus that influences ACC and MCC boundaries, is prominent in approximately 30-60% of individuals, with higher incidence on the left hemisphere and potential asymmetry affecting regional volumes. Additionally, the cingulate sulcus itself may appear as a single continuous structure or segmented with double parallel folds in some cases.^[5]^[7]

Cytoarchitecture

The cytoarchitecture of the cingulate cortex is characterized by distinct Brodmann areas across its major subdivisions. The anterior cingulate cortex (ACC) encompasses Brodmann areas 24, 25, 32, and 33, while the midcingulate cortex (MCC) corresponds to the posterior portion of area 24 (often denoted as 24'). The posterior cingulate cortex (PCC) includes areas 23, 29, 30, and 31, and the retrosplenial cortex (RSC) overlaps with areas 29 and 30.^[1]^[8] Layering in the cingulate cortex varies regionally, reflecting functional specialization. The ACC is agranular, lacking a well-developed layer IV and instead featuring prominent layers V and VI that support output projections.^[8] In contrast, the MCC exhibits dysgranular characteristics as a transitional zone, with a partially developed layer IV. The PCC and RSC are granular, displaying a prominent layer IV that facilitates sensory integration.^[9]^[1] Principal cell types include pyramidal neurons, which predominate in the deep layers (V and VI) across regions and serve as projection neurons. Superficial layers (II and III) contain a higher proportion of interneurons for local modulation. Notably, the ACC hosts spindle-shaped von Economo neurons (VENs) in layer Vb, which are large, bipolar cells adapted for rapid signaling in emotional and social contexts.^[8]^[10] Histological staining techniques, such as Nissl (using thionin or cresyl violet) and Golgi methods, highlight these features by revealing laminar organization and neuronal morphology. These approaches demonstrate denser neuronal packing in the PCC, particularly in layers III and IV, compared to the sparser arrangement in the ACC's layer Vb.^[8]^[11]

Connectivity

Afferent inputs

The cingulate cortex receives a diverse array of afferent projections from subcortical and cortical structures, enabling its integration of cognitive, emotional, and sensory information. These inputs are topographically organized, with the anterior cingulate cortex (ACC) and posterior cingulate cortex (PCC) serving as primary recipients based on their distinct roles in processing. Thalamic nuclei provide dense afferent inputs to the cingulate cortex, differing between its anterior and posterior divisions. The ACC is innervated predominantly by the mediodorsal nucleus (MD), midline nuclei (e.g., paraventricular, paratenial, and reuniens), and intralaminar nuclei (e.g., centrolateral and parafascicular), which relay signals related to attention, motivation, and cognitive control; these projections form a major component of ACC afferents, with dense labeling observed across multiple nuclei in tracing studies. In contrast, the PCC receives prominent inputs from the anterior thalamic nuclei (anteroventral and anteromedial) and the lateral dorsal nucleus, supporting spatial orientation and episodic memory integration. These thalamic pathways underscore the cingulate's role as a relay hub for limbic and associative processing. Frontal cortical regions contribute key afferents to the ACC, facilitating decision-making and executive functions. The orbitofrontal cortex (OFC) projects bilaterally to rostral and pregenual ACC subregions, conveying reward valuation and outcome evaluation signals essential for adaptive behavior. Similarly, the dorsolateral prefrontal cortex (DLPFC) sends projections to mid- and caudal ACC areas, integrating working memory and conflict monitoring to guide cognitive flexibility. Limbic structures supply emotionally salient inputs to both ACC and PCC divisions. The amygdala, particularly its basolateral nucleus, projects directly to the ACC, transmitting fear, anxiety, and affective valence information that modulates emotional responses. The hippocampus provides inputs to the PCC, primarily via intermediary relays in the parahippocampal gyrus (including entorhinal and perirhinal areas), enabling the incorporation of contextual and autobiographical memory traces into spatial navigation. Sensory afferents reach the cingulate cortex through thalamic and cortical relays, emphasizing its involvement in multimodal integration. Nociceptive signals from the spinothalamic tract are relayed via posterior and intralaminar thalamic nuclei to mid- and posterior ACC regions, supporting the affective-motivational dimension of pain perception. Visual and auditory sensory information is conveyed from parietal association areas (e.g., superior and inferior parietal lobules) to the PCC, aiding in visuospatial awareness and environmental mapping.

Efferent outputs

The efferent projections of the cingulate cortex originate primarily from its subdivisions, including the anterior cingulate cortex (ACC), midcingulate cortex (MCC), and posterior cingulate cortex (PCC), and target diverse brain regions to integrate cognitive, emotional, and motor functions. These outputs are predominantly ipsilateral, with some contralateral connections mediated by the corpus callosum, facilitating interhemispheric coordination.^[12] The ACC sends prominent projections to prefrontal regions, including the dorsolateral prefrontal cortex (DLPFC) and orbitofrontal cortex (OFC), supporting executive control and reward-based decision-making. Specifically, the ACC connects to the ventromedial prefrontal cortex (vmPFC) and medial prefrontal area 10, influencing cognitive flexibility and emotional valuation. Additionally, the MCC, often considered a motor-oriented extension of the ACC, projects to the supplementary motor area (SMA) and premotor cortex (area 6), as well as the basal ganglia (particularly the striatum), aiding in action selection and motor planning.^[12]^[13] Limbic targets receive inputs from multiple cingulate subdivisions: the PCC projects to the hippocampus and entorhinal cortex via the parahippocampal gyrus, contributing to memory consolidation and spatial navigation. The ACC, in turn, connects to the hypothalamus, modulating autonomic responses and motivational states. Descending projections from the ACC also reach the brainstem, notably the periaqueductal gray (PAG), where they influence pain modulation and defensive behaviors.^[12]

Integration in brain networks

The posterior cingulate cortex (PCC) functions as a core hub within the default mode network (DMN), supporting self-referential processing and internally directed cognition through coordinated activity during rest.^[14] This hub maintains strong functional connectivity with the medial prefrontal cortex, which contributes to autobiographical memory and future-oriented thinking, as well as with the angular gyrus in the parietal lobe, facilitating integration of spatial and semantic information.^[15] These connections enable the DMN's role in mind-wandering and social cognition, with the PCC acting as a central integrator across midline and lateral cortical regions.^[16] In the salience network, the anterior cingulate cortex (ACC) plays a pivotal role in detecting environmentally relevant stimuli and initiating adaptive responses.^[17] It achieves this by linking with the anterior insula to process interoceptive and exteroceptive signals, thereby signaling the salience of events that demand attention.^[18] Additionally, the ACC connects to the temporoparietal junction to support rapid attention shifts, particularly in social contexts requiring reorientation toward unexpected or behaviorally significant cues.^[17] The midcingulate cortex (MCC) integrates into the executive control network, where it coordinates with frontoparietal regions to monitor cognitive conflict and adjust control allocation.^[19] This coordination involves detecting discrepancies between expected and actual outcomes, enabling dynamic resource deployment for task performance.^[20] Such network participation underscores the MCC's contribution to higher-order supervisory processes, distinct from more localized conflict signals in the ACC.^[21] Recent functional connectivity analyses have revealed intrinsic gradients along the cingulate cortex, organizing it hierarchically from anterior regions associated with task-positive activation to posterior regions linked to task-negative deactivation.^[22] These gradients, identified in 2023 studies, capture three principal dimensions of organization, reflecting transitions in network affiliation and processing demands across subdivisions.^[22] Complementing this, diffusion tensor imaging (DTI) demonstrates that the cingulum bundle serves as a primary white matter tract for intra-cingulate communication, with fractional anisotropy variations indicating robust microstructural support for interconnecting frontal, parietal, and temporal aspects of the cingulate.^[23]

Functions

Cognitive processing

The anterior cingulate cortex (ACC) plays a central role in error detection and conflict monitoring during cognitive tasks. In tasks like the Stroop color-word interference test, where participants must resolve competing response tendencies, the ACC activates to signal response conflicts, enabling subsequent adjustments in behavior.^[24] This process aligns with the conflict-monitoring hypothesis, which posits that the ACC detects mismatches between intended and executed actions or between stimulus features, thereby recruiting prefrontal resources for resolution.^[25] Electrophysiological studies further reveal that theta-band oscillations (4-8 Hz) in the ACC index this conflict detection, increasing during high-conflict trials to facilitate adaptive control.^[26] In decision-making, the midcingulate cortex (MCC), a dorsal extension of the ACC, integrates cost-benefit analyses to guide action selection, particularly in foraging-like paradigms where individuals weigh exploitation of current options against exploration of alternatives. Functional imaging shows MCC activation correlates with subjective value computations, such as estimating patch quality in resource-gathering tasks modeled after optimal foraging theory. This supports flexible choice under uncertainty, where MCC signals promote shifts from habitual to exploratory behaviors when rewards diminish.^[27] The posterior cingulate cortex (PCC) contributes to attention allocation by linking spatial orientation with internal representations, aiding in the prioritization of relevant environmental cues. During tasks requiring anticipatory shifts in spatial attention, PCC activation facilitates the integration of visuospatial information with ongoing goals, enhancing orienting responses.^[28] Additionally, the PCC supports autobiographical memory retrieval, where it retrieves self-referential episodes to inform attentional focus, as seen in functional MRI studies of episodic recall.^[29] Working memory maintenance in the cingulate involves ACC-prefrontal cortex (PFC) loops that sustain goal representations amid interference. These circuits, evident in tasks demanding sustained attention to rules or targets, allow the ACC to bias PFC activity toward relevant information, preventing decay of active goals.^[30] Such loops ensure that cognitive control adapts to fluctuating demands, with ACC signaling when goal conflicts arise to reinforce mnemonic stability. Recent research highlights ACC functional gradients that underpin adaptive cognition in dynamic environments. A 2023 study mapping cingulate connectivity gradients revealed a principal axis radiating from midcingulate regions, correlating with transitions in cognitive flexibility during variable task contexts.^[31] These gradients reflect how ACC subdivisions scale processing from routine to novel demands, informing models of real-world adaptability.

Emotional and motivational regulation

The cingulate cortex is integral to emotional and motivational regulation, integrating affective signals to influence behavior and internal states. The perigenual anterior cingulate cortex (pgACC) contributes to the generation and maintenance of positive affect, such as happiness, by modulating emotional responses to rewarding or affiliative stimuli.^[32] In contrast, the subgenual anterior cingulate cortex (sgACC) is prominently involved in negative emotional states, including sadness and rumination, where heightened activity sustains prolonged negative mood and impairs cognitive flexibility during affective distress.^[33]^[34] These subdivisions receive emotional inputs from the amygdala, enabling the cingulate to appraise and regulate valence-specific responses.^[2] In reward processing, the anterior cingulate cortex (ACC) encodes prediction errors, signaling discrepancies between anticipated and actual outcomes to update motivational value, with dopaminergic modulation from the ventral tegmental area (VTA) enhancing learning from rewarding events.^[35]^[36] This mechanism supports adaptive behavior by prioritizing actions associated with positive reinforcement, distinguishing the ACC's role in affective valuation from purely cognitive error detection. Motivational drives are shaped by interactions between the orbitofrontal cortex (OFC) and ACC, which together evaluate reward contingencies to guide goal-directed actions and foster empathy by simulating others' emotional states.^[37]^[38] The posterior cingulate cortex (PCC), operating within the default mode network (DMN), further aids social motivation through theory of mind processes, enabling inference of others' intentions and emotions during introspective or interpersonal contexts.^[39]^[40] Emerging evidence links cingulate function to broader neural plasticity, with 2023 studies highlighting the ACC's role in promoting adult hippocampal neurogenesis, a process that enhances mood stability by facilitating emotional memory consolidation and resilience to stress.^[41]

Autonomic and pain modulation

The anterior cingulate cortex (ACC) exerts significant influence over autonomic functions, particularly in modulating cardiovascular responses such as heart rate variability and blood pressure. This regulation occurs primarily through direct and indirect projections from the ACC to the hypothalamus, which integrates emotional and cognitive signals to adjust sympathetic and parasympathetic outflows. For instance, ACC activity has been shown to correlate with blood pressure fluctuations during stress, supporting its role in adaptive autonomic responses to environmental demands. Similarly, functional connectivity between the dorsal ACC and brainstem structures covaries with high-frequency heart rate variability, a marker of parasympathetic tone. These mechanisms enable the ACC to fine-tune visceral responses in concert with ongoing cognitive and emotional processing. In pain processing, the ACC serves as a critical hub for the affective dimension of nociception, encoding the emotional distress and motivational urgency associated with painful stimuli, in contrast to the sensory-discriminative processing handled by lateral thalamic nuclei. This affective encoding contributes to the subjective unpleasantness of pain, integrating sensory inputs with emotional valence to drive avoidance behaviors. The ACC frequently co-activates with the anterior insula during noxious stimulation, forming a network that amplifies the salience of pain through shared processing of interoceptive and affective signals. Nociceptive information reaches the ACC via the lamina I spinothalamic tract, which relays wide-dynamic-range and nociceptive-specific projections from spinal dorsal horn neurons to medial thalamic nuclei, ultimately conveying signals that represent pain unpleasantness and suffering. Endogenous opioid systems further modulate ACC activity to promote analgesia, particularly through descending pathways involving periaqueductal gray (PAG)-ACC loops. These circuits release endogenous opioids like enkephalins within the ACC and PAG, dampening affective pain responses by inhibiting nociceptive transmission and reducing perceived unpleasantness. Activation of mu-opioid receptors in the ACC, for example, selectively suppresses pain-related neuronal firing, contributing to placebo and stress-induced analgesia. Recent functional MRI studies have revealed ACC hyperactivation in chronic pain syndromes, such as fibromyalgia and neuropathic pain, where heightened baseline activity and exaggerated responses to stimuli reflect maladaptive amplification of affective pain components. This hyperactivation persists even in resting states, underscoring the ACC's role in sustaining chronic distress.

Development

Embryonic origins

The cingulate cortex originates from the dorsal telencephalon, which emerges from the prosencephalon (forebrain) during early human embryogenesis around gestational weeks 5 to 6. At this stage, the prosencephalon divides into the telencephalon and diencephalon, with the telencephalic vesicles expanding bilaterally to form the foundational structures of the cerebral hemispheres; the medial aspects of these vesicles give rise to the cingulate primordium as part of the allocortical plate.^[1] This early differentiation establishes the cingulate as a transitional zone between the archicortex (e.g., hippocampal formation) and the neocortex, setting the stage for its later subdivisions into anterior, mid, and posterior regions. Neuronal precursors in the ventricular zone of the dorsal telencephalon undergo proliferation, followed by radial glial-guided migration to populate the cingulate primordium. These radial glia serve as scaffolds, directing postmitotic neurons outward along their processes to form the initial laminar organization of the cortical plate in the medial wall.^[42] This migration pattern is conserved across medial cortical regions, ensuring precise positioning of early-generated neurons that will contribute to the cingulate's foundational circuitry. The process peaks during weeks 6 to 8, coinciding with the transition from pseudostratified epithelium to a multilayered structure. Key transcription factors, including Emx2 and Pax6, play critical roles in patterning the cingulate primordium by establishing rostrocaudal and mediolateral identities in the pre-neuronogenic cortical field. Emx2 promotes cingulate-specific gene expression (e.g., Wnt3a), while Pax6 restricts it to prevent neocortical expansion into medial territories; loss-of-function mutations in Emx2 reduce or eliminate cingulate markers, whereas Pax6 mutants exhibit the opposite effect, leading to altered regional boundaries as early as embryonic day 12.5 in mouse models, analogous to human week 7.^[43]^[44] The initial morphological distinction of the cingulate occurs with the emergence of the cingulate sulcus around gestational weeks 20 to 24, representing one of the earliest primary indentations on the medial hemispheric surface and preceding corpus callosum formation by several weeks.^[45] This shallow furrow delineates the superior boundary of the prospective cingulate gyrus, driven by differential growth rates between the medial wall and adjacent structures. Disruptions in prosencephalic cleavage, as seen in holoprosencephaly, can result in abnormal or hypoplastic cingulate gyrus due to incomplete midline separation, manifesting as fused or absent medial cortical structures in severe cases.^[46]

Postnatal maturation and plasticity

The postnatal development of the cingulate cortex involves significant structural and functional refinements that enhance its role in cognitive and emotional processing. Following birth, the cingulate cortex undergoes progressive myelination, particularly along the cingulum bundle, which serves as a major white matter tract connecting anterior and posterior regions. This myelination process accelerates during childhood and peaks in adolescence, typically between ages 10 and 20, leading to improved axonal conduction speeds and strengthened inter-regional connectivity within limbic and prefrontal networks.^[47]^[48] Synaptic maturation in the anterior cingulate cortex (ACC) follows a pattern of initial overproduction followed by selective elimination. During infancy, there is a surge in synaptogenesis, peaking around 8 months in prefrontal areas including the ACC, which supports rapid early learning and sensory integration. Subsequent synaptic pruning refines these connections for efficiency, with substantial reductions occurring by early childhood (around age 5) in the ACC, eliminating weaker synapses to optimize circuit specificity and reduce metabolic demands.^[49]^[50] Plasticity in the cingulate cortex persists postnatally, enabling adaptive responses to environmental stimuli through mechanisms like long-term potentiation (LTP). Brain-derived neurotrophic factor (BDNF) plays a key role in mediating LTP in the ACC, where its release during learning experiences strengthens synaptic efficacy and supports memory consolidation. This BDNF-dependent plasticity is evident in both anterior and posterior regions, facilitating behavioral adaptations throughout development.^[51]^[52] Pubertal hormonal changes further modulate cingulate structure, particularly influencing ACC volume. Elevated testosterone levels during puberty are negatively correlated with ACC gray matter volume, potentially refining emotional regulation circuits in a sex-specific manner, while estrogen may promote volumetric stability or growth in females. These shifts contribute to the maturation of motivational and cognitive functions.^[53] Recent 2025 research highlights ongoing plasticity in the posterior cingulate cortex (PCC) relevant to aging and injury recovery. Mindfulness-based interventions have been suggested to increase gray matter density in the PCC, with potential benefits for cognitive restoration through enhanced default mode network integrity in individuals recovering from mild traumatic brain injury.^[54] In aging populations, physical activity promotes PCC neuroplasticity, mitigating connectivity declines and supporting memory resilience against neurodegenerative processes, as evidenced by improvements in gray matter density and cognitive function.^[55] Recent neuroimaging studies as of 2025 using diffusion tensor imaging have further elucidated early postnatal trajectories of cingulate connectivity, highlighting genetic-epigenetic influences on maturation and links to neurodevelopmental disorders.^[55]

Clinical significance

Psychiatric disorders

The anterior cingulate cortex (ACC) exhibits hypoactivity during cognitive tasks in individuals with schizophrenia, contributing to deficits in error monitoring and executive function.^[56] Structural imaging studies have identified significant volume reductions in Brodmann area 24 (BA24), the dorsal ACC region, in chronic cases, linked to illness duration and symptom severity.^[57] In major depressive disorder (MDD), the subgenual ACC (sgACC) shows hyperactivity during rumination, a core cognitive process involving repetitive negative self-focus that perpetuates depressive symptoms.^[58] Recent 2025 meta-analyses confirm reduced connectivity between the posterior cingulate cortex (PCC) and the default mode network (DMN) in MDD, associated with impaired self-referential processing and emotional dysregulation.^[59] Alterations in the midcingulate cortex (MCC) are observed in attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder, particularly affecting attention allocation and social processing, as evidenced by reduced gray matter volume in the right MCC among children with ADHD.^[60] Additionally, decoupling between the ACC and amygdala is noted in both conditions, leading to impaired emotion recognition and social cue integration in autism and heightened emotional reactivity in ADHD.^[61]^[62] Bipolar disorder involves volumetric changes in the ACC that correlate with mood episode frequency, including reductions in subgenual ACC volume following manic episodes, which may underlie mood instability and cognitive impairments.^[63]^[64] Functional MRI (fMRI) studies reveal task-based hypoactivation in the salience network, including the ACC, across psychiatric disorders, reflecting deficits in emotion regulation and attentional shifting to relevant stimuli.^[65] This pattern underscores the ACC's role in integrating cognitive and affective signals, with disruptions contributing to transdiagnostic symptoms like anhedonia and impulsivity.^[66]

Neurological conditions

The posterior cingulate cortex (PCC) exhibits early tau pathology and atrophy in Alzheimer's disease (AD), contributing to memory loss through disruption of the default mode network (DMN). Tau neurofibrillary tangles accumulate in the PCC during the preclinical and mild cognitive stages of AD, often following initial deposition in the entorhinal cortex, and this pathology correlates with synaptic loss and neuronal dysfunction in the region.^[67] Atrophy of the PCC is detectable in incipient AD and is associated with episodic memory deficits, as volumetric reductions in this area predict cognitive decline independently of hippocampal changes.^[68]^[69] Furthermore, AD-related tau and amyloid-beta burdens in the PCC lead to hypometabolism and functional disconnection within the DMN, impairing memory retrieval and spatial orientation.^[70]^[71] In healthy aging, thinning of the PCC cortex correlates with declines in episodic memory performance, reflecting age-related structural vulnerability without overt pathology. Cortical thickness reductions in the PCC, observed via magnetic resonance imaging, are linked to subclinical memory impairments and reduced functional connectivity in memory networks, even in cognitively intact older adults.^[72]^[73] These changes contribute to broader cognitive slowing, with PCC thinning serving as a biomarker for age-associated memory vulnerability.^[74] The anterior cingulate cortex (ACC) can serve as a seizure focus in cingulate epilepsy, a rare form of focal epilepsy characterized by drug-resistant seizures originating in the cingulate gyrus. Seizures in cingulate epilepsy often present with motor, autonomic, or emotional symptoms due to the ACC's role in integrating sensory and limbic inputs, and invasive electroencephalography is typically required for precise localization in non-lesional cases.^[75] Surgical resections targeting the ACC or broader cingulate regions yield favorable outcomes, with many patients achieving seizure freedom or significant reduction post-operatively, though risks include transient cognitive or emotional changes.^[76]^[77] Traumatic brain injury (TBI) frequently involves diffuse axonal injury (DAI) in the cingulum bundle, leading to cognitive deficits such as impaired attention, memory, and executive function. The cingulum bundle, a major white matter tract connecting cingulate regions to frontal and temporal lobes, sustains shear-strain damage in moderate to severe TBI, resulting in fractional anisotropy reductions detectable by diffusion tensor imaging.^[78] This injury disrupts frontocingulate networks, correlating with persistent cognitive impairments in chronic TBI survivors, including deficits in working memory and emotional regulation.^[79]^[80] Recent 2024 studies highlight the PCC's vulnerability in mild cognitive impairment (MCI), positioning it as a key early marker for progression to dementia. Aberrant functional connectivity between the PCC and retrosplenial cortex, observed in MCI patients, predicts memory decline and differentiates MCI from normal aging, with reduced PCC-hippocampal coupling linked to amyloid accumulation.^[81] MicroRNA dysregulation in the PCC distinguishes MCI from resilient cognition and AD, underscoring its role in synaptic vulnerability during the MCI stage.^[82] Additionally, multimodal analyses in 2024 confirm PCC hypometabolism and atrophy as predictors of dementia conversion in MCI, independent of traditional biomarkers like hippocampal volume.^[83]

Therapeutic interventions

Deep brain stimulation (DBS) targeting the subgenual anterior cingulate cortex (sgACC) has emerged as a promising intervention for treatment-resistant depression (TRD), involving the implantation of electrodes to deliver electrical impulses that modulate dysfunctional neural circuits. Clinical trials have demonstrated response rates of approximately 60% in patients with TRD, with sustained benefits observed up to several years post-implantation. For instance, a 2025 study reported a 60% remission rate when stimulating the rostral extension of the prefrontal cortex linked to sgACC pathways, highlighting its role in alleviating persistent depressive symptoms unresponsive to conventional therapies.^[84]^[85] Cingulotomy, an ablative neurosurgical procedure that lesions the anterior cingulate cortex, has been employed historically since the mid-20th century for obsessive-compulsive disorder (OCD) and chronic intractable pain, with modern iterations using stereotactic techniques for precision and reduced invasiveness. In OCD cases refractory to pharmacotherapy and psychotherapy, cingulotomy interrupts hyperactive cingulate-prefrontal loops, yielding symptom improvement in up to 50% of patients based on long-term follow-up data. For chronic pain, particularly neoplastic and non-neoplastic types, it provides relief in 43-64% of cases at six months, often by diminishing the emotional distress component of pain perception without altering sensory thresholds.^[86]^[87] Transcranial magnetic stimulation (TMS), particularly high-frequency repetitive TMS (rTMS), indirectly modulates anterior cingulate cortex (ACC) activity through stimulation of overlying prefrontal regions, offering a non-invasive option for depression with remission rates around 30-40% in TRD populations. Protocols targeting the dorsolateral prefrontal cortex, which influences ACC connectivity, have shown antidepressant effects by normalizing sgACC hyperactivity, as evidenced in randomized trials where responders exhibited enhanced ACC functional coupling post-treatment. This approach is FDA-approved for TRD and provides an alternative to invasive methods, with sessions typically lasting 4-6 weeks.^[88]^[89] Pharmacotherapy targeting cingulate serotonin systems includes selective serotonin reuptake inhibitors (SSRIs), which enhance serotonin availability in the ACC to mitigate anxiety symptoms by retuning emotional processing biases. In anxiety disorders, SSRIs like sertraline reduce ACC hyperactivation during threat processing, leading to symptom remission in over 50% of patients after 8-12 weeks, as supported by neuroimaging studies showing normalized ACC-amygdala connectivity. Additionally, ketamine, a rapid-acting antidepressant, alters posterior cingulate cortex (PCC) connectivity within the default mode network, decreasing aberrant resting-state functional correlations associated with depressive rumination and yielding acute symptom relief in 70% of TRD cases within hours of infusion.^[90]^[91]^[92] Neurofeedback using real-time functional MRI (rtfMRI) enables patients to self-regulate ACC activity for pain management, training individuals to upregulate or downregulate rostral ACC signals to modulate pain perception. Seminal clinical studies have shown that after 3-5 sessions, participants can achieve voluntary control over ACC activation, resulting in a 20-40% reduction in subjective pain ratings during evoked pain tasks, with effects persisting for weeks. This technique is particularly beneficial for chronic pain conditions like fibromyalgia, offering a non-pharmacological means to enhance endogenous pain modulation without side effects common to medications.^[93]^[94]^[95]

History and research

Early anatomical descriptions

The earliest visual representations of the medial brain folds, which include the rudimentary depiction of what would later be identified as the cingulate cortex, appeared in Andreas Vesalius's seminal anatomical atlas De humani corporis fabrica published in 1543. These illustrations, based on human cadaver dissections, portrayed the brain's internal structures with unprecedented accuracy for the time, showing the curved folds along the medial surface above the corpus callosum, though without specific nomenclature for the region.^[96] In the 17th century, English physician and anatomist Thomas Willis provided the first detailed description of the structure in his 1664 work Cerebri anatome, naming it the "gyrus cinguli" for its girdle-like encirclement of the corpus callosum. Willis's account, illustrated by Christopher Wren, emphasized the gyrus's position on the medial brain surface and its continuity with adjacent folds, marking a foundational step in neuroanatomy by distinguishing it from surrounding cortical regions.^[97] The 19th century saw further refinement in nomenclature and functional associations. French neurologist Paul Broca, in his 1878 anatomical studies, introduced the term "limbus" (Latin for border) to describe the marginal cortical structures forming the "grand lobe limbique," which encompassed the cingulate gyrus and parahippocampal regions, linking them to olfactory and instinctual functions. Concurrently, the term "cingulum" was established for the underlying white matter bundle running parallel to the gyrus, reflecting its belt-like trajectory beneath the cortical surface. In 1909, German neurologist Korbinian Brodmann advanced the anatomical mapping in Vergleichende Lokalisationslehre der Großhirnrinde, delineating the cingulate cortex into cytoarchitectonic areas 23 through 31 based on cellular organization, providing a precise parcellation that remains influential.^[98]^[99] By the early 20th century, prior to World War II, the cingulate's role in emotion gained prominence through James Papez's 1937 proposal of the Papez circuit, a neural pathway integrating the cingulate cortex with the hippocampus, fornix, mammillary bodies, and anterior thalamus to mediate emotional processing and expression. This conceptualization positioned the cingulate as a key relay in the cortical-subcortical loop for affective integration, building directly on earlier anatomical foundations.^[100]

Modern neuroscientific advancements

In the mid-20th century, Paul D. MacLean's expansion of the limbic system concept in the 1950s and 1960s integrated the cingulate cortex as a core component linking visceral and emotional functions, building on Papez's circuit to encompass the amygdala, hypothalamus, and orbital cortex in his triune brain model.^[101] This framework, formalized in MacLean's 1952 paper, positioned the anterior cingulate cortex (ACC) within a phylogenetically conserved system for affective regulation, influencing subsequent research on emotion and motivation.^[102] Early electrophysiological studies during this era, including initial EEG explorations of limbic structures, began revealing cingulate involvement in emotional tasks, though recordings were limited by invasive methods in animal models.^[103] The advent of functional neuroimaging in the 1990s marked a pivotal shift, with event-related fMRI studies demonstrating the ACC's role in error detection and conflict monitoring during cognitive tasks.^[104] Carter et al.'s 1998 seminal work showed ACC activation in response to errors on the Stroop task, establishing it as a key node for online performance monitoring and adaptive control.^[104] Concurrently, the discovery of the default mode network (DMN) highlighted the posterior cingulate cortex (PCC) as a central hub for internally directed cognition, with Raichle et al.'s 2001 analysis of resting-state PET data revealing its anticorrelations with task-positive networks.^[105] Advancements in the 2000s and 2010s introduced circuit-level precision through optogenetics and structural imaging. Optogenetic manipulations in rodent models confirmed the ACC's causal role in pain processing, with selective activation of inhibitory neurons reducing nocifensive behaviors in chronic pain states.^[106] Diffusion tensor imaging (DTI) enabled connectomic mapping of the cingulum bundle, quantifying white matter integrity and its disruptions in disorders like mild cognitive impairment, where reduced fractional anisotropy in cingulum fibers correlated with memory deficits.^[107] Recent studies from 2023 to 2025 have highlighted the significance of the ACC in neurogenesis plasticity, particularly its connections and functions in regulating adult neurogenesis related to memory and cognitive processes under stress.^[108] AI-driven analyses of functional connectivity gradients have delineated the cingulate's hierarchical organization, identifying three principal gradients—from sensory-motor to transmodal integration—that underpin its role in attention and decision-making, derived from large-scale resting-state fMRI datasets.^[31] A 2025 sham-controlled trial of deep brain stimulation (DBS) targeting the subgenual cingulate for treatment-resistant depression, followed by open-label extension, reported response rates of 65-73% at 12-24 months in the extension phase.^[109] These developments reflect a broader methodological evolution in cingulate research, transitioning from invasive lesion studies—reliant on animal models and human case reports—to non-invasive techniques like fMRI and DTI, which allow in vivo assessment of dynamic function and connectivity without ethical constraints.^[110] This shift has expanded understanding beyond early associations with schizophrenia to multifaceted roles in cognition, emotion, and network integration.^[111]

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