Surgical morbidity of transsylvian versus transcortical approaches to insular gliomas

OBJECTIVEThe choice of transsylvian versus transcortical corridors for resection of insular gliomas remains controversial. Functional pathway compromise from transcortical transgression and vascular injury during transsylvian dissection are the primary concerns. In this study, data from a single-center experience with both approaches were compared to determine whether one approach was associated with a higher rate of morbidity than the other.METHODSThe authors identified 100 consecutive patients who underwent resection of pure insular gliomas at the Barrow Neurological Institute. Volumetric analysis was performed using FLAIR and contrast-enhanced T1-weighted MRI for low- and high-grade gliomas, respectively, for extent of resection (EOR) and diffusion-weighted sequences were used to detect for postoperative ischemia. Step-wise logistic regression analysis was performed to identify predictors of neurological morbidity.RESULTSData from 100 patients with low-grade or high-grade insular gliomas were analyzed. Fifty-two patients (52%) underwent a transsylvian approach, and 48 patients (48%) underwent a transcortical approach. The mean (± SD) EOR was 91.6% ± 12.4% in the transsylvian group and 88.6% ± 14.2% in the transcortical group (p = 0.26). Clinical outcome metrics for the 2 groups were similar. Overall, 13 patients (25%) in the transsylvian group and 10 patients (21%) in the transcortical group had evidence of ischemia on postoperative MR images. For both approaches, high-grade histology was associated with permanent morbidity (p = 0.01). For patients with gliomas located within the superior-posterior quadrant of the insula, development of postoperative ischemia was associated with only the transsylvian approach (46% vs 0%, p = 0.02).CONCLUSIONSAreas of restricted diffusion are common on postoperative MRI following resection of insular gliomas, but only a minority of these patients develop permanent neurological deficits. Insular glioma patients with high-grade histology may be at particular risk for developing symptomatic postoperative ischemia. Both the transcortical and transsylvian corridors are associated with reasonable morbidity profiles, although gliomas situated within the superior-posterior quadrant of the insula are more safely accessed with a transcortical approach.

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SURG-32. THE USE OF 5-AMINOLEVULINIC ACID IN LOW-GRADE GLIOMA RESECTION: A SYSTEMATIC REVIEW

Neuro-Oncology ◽

10.1093/neuonc/noz175.1032 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi246-vi246

Author(s):

Ahmad Almekkawi ◽

Tarek El Ahmadieh ◽

Karl Abi-Aad ◽

Salah Aoun ◽

Najib EL Tecle ◽

...

Keyword(s):

Systematic Review ◽

Quality Index ◽

Aminolevulinic Acid ◽

High Grade Glioma ◽

Extent Of Resection ◽

Low Grade Glioma ◽

Low Grade ◽

High Grade ◽

Visualization Technology ◽

Glioma Resection

Abstract BACKGROUND 5-aminolevulinic acid is a reliable tool for optimizing high-grade glioma resection. However, its efficacy in low-grade glioma resection remains unclear. OBJECTIVE To study the role of 5-aminolevulinic acid in low-grade glioma resection and assess positive fluorescence rates and effect on the extent of resection. METHODS A systematic review of PubMed, Google Scholar, and Cochrane was performed from the date of inception to February 1, 2019. Studies that correlated 5-aminolevulinic acid fluorescence with low-grade glioma in the setting of operative resection were selected. Studies with biopsy only were excluded. Positive fluorescence rates were calculated. Quality index of the selected papers using the Downs and Black criteria checklist was provided. RESULTS Twelve articles met the selection criteria with 244 histologically-confirmed low-grade glioma patients who underwent microsurgical resection. All patients received 20 mg/kg body weight of 5-aminolevulinic acid. Only 60 patients (n=60/244; 24.5%) demonstrated visual intra-operative 5-aminolevulinic acid fluorescence. The extent of resection was reported in 4 studies, however, the data combined low- and high-grade tumors. Only 2 studies reported on tumor location. Only 3 studies reported on clinical outcomes. The Zeiss OPMI Pentero microscope was most commonly used across all studies. The average quality index was 14.58 (range: 10–17) which correlated with an overall good quality. CONCLUSION There is an overall low correlation between 5-aminolevulinic acid fluorescence and low-grade glioma. Advances in visualization technology and using standardized fluorescence quantification methods may further improve the visualization and reliability of 5-aminolevulinic acid fluorescence in low-grade glioma resection.

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Surgery for low-grade glioma infiltrating the central cerebral region: location as a predictive factor for neurological deficit, epileptological outcome, and quality of life

Journal of Neurosurgery ◽

10.3171/2013.5.jns122235 ◽

2013 ◽

Vol 119 (2) ◽

pp. 318-323 ◽

Cited By ~ 37

Author(s):

Philippe Schucht ◽

Fadi Ghareeb ◽

Hugues Duffau

Keyword(s):

Quality Of Life ◽

Return To Work ◽

Seizure Control ◽

Extent Of Resection ◽

Low Grade Glioma ◽

Neurological Deficits ◽

Main Concern ◽

Low Grade ◽

Who Grade

Object A main concern with regard to surgery for low-grade glioma (LGG, WHO Grade II) is maintenance of the patient's functional integrity. This concern is particularly relevant for gliomas in the central region, where damage can have grave repercussions. The authors evaluated postsurgical outcomes with regard to neurological deficits, seizures, and quality of life. Methods Outcomes were compared for 33 patients with central LGG (central cohort) and a control cohort of 31 patients with frontal LGG (frontal cohort), all of whom had had medically intractable seizures before undergoing surgery with mapping while awake. All surgeries were performed in the period from February 2007 through April 2010 at the same institution. Results For the central cohort, the median extent of resection was 92% (range 80%–97%), and for the frontal cohort, the median extent of resection was 93% (range 83%–98%; p = 1.0). Although the rate of mild neurological deficits was similar for both groups, seizure freedom (Engel Class I) was achieved for only 4 (12.1%) of 33 patients in the central cohort compared with 26 (83.9%) of 31 patients in the frontal cohort (p < 0.0001). The rate of return to work was lower for patients in the central cohort (4 [12.1%] of 33) than for the patients in the frontal cohort (28 [90.3%] of 31; p < 0.0001). Conclusions Resection of central LGG is feasible and safe when appropriate intraoperative mapping is used. However, seizure control for these patients remains poor, a finding that contrasts markedly with seizure control for patients in the frontal cohort and with that reported in the literature. For patients with central LGG, poor seizure control ultimately determines quality of life because most will not be able to return to work.

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Intraoperative 5-ALA Fluorescence-Guided Resection of High-Grade Glioma Leads to Greater Extent of Resection with Better Outcomes: A Systematic Review

10.21203/rs.3.rs-845224/v1 ◽

2021 ◽

Author(s):

Tiffany Eatz ◽

Daniel Eichberg ◽

Victor Lu ◽

Long Di ◽

Ricardo Jorge Komotar ◽

...

Keyword(s):

Systematic Review ◽

White Light ◽

Randomized Clinical Trials ◽

Aminolevulinic Acid ◽

High Grade Glioma ◽

Extent Of Resection ◽

Fluorescent Imaging ◽

Neurological Deficits ◽

High Grade ◽

Significant Difference

Abstract ImportanceHigh-grade gliomas (HGG) are the most aggressive and common malignant brain tumors in adults. They have a dismally fatal prognosis. Even if gross total resection of the enhancing tumor is achieved, inevitably, invading tumor cells that are indistinguishable to the un-aided eye are left behind, which eventually leads to tumor recurrence. 5-aminolevulinic acid (5-ALA) is an increasingly utilized intraoperative fluorescent imaging agent for patients with HGG. It enhances visualization of HGG tissue. Despite early promising randomized clinical trial data suggesting a survival benefit for 5-ALA-guided surgery, the growing body of literature must be analyzed to confirm efficacy on patient outcomes.Objective To perform a systematic review of the literature to evaluate whether there is a beneficial effect upon survival and extent of resection due to the utilization of 5-ALA in HGG surgery. Evidence ReviewLiterature regarding 5-ALA usage in HGG surgery was reviewed according to the PRISMA guidelines. One database, PubMed, was searched for assorted combinations of the keywords “5-ALA,” “high-grade glioma,” “5-aminolevulinic acid,” and “resection” in July 2020 for case reports and retrospective, prospective, and randomized clinical trials assessing and analyzing 5-ALA intraoperative use in patients with HGG. Entailed studies on PubMed and SCOPUS were found for screening using a snowball search technique upon the initially searched PubMed papers. Systematic reviews and meta-analyses were excluded from our PRISMA table. Findings1,951 previously published studies were screened, 536 of which were further evaluated, and ultimately 45 were included in our systematic review. There were no date restrictions on the screened publications. Our literature search was finalized on July 16, 2020. We found an observed increase in the overall survival (OS) and progression-free survival (PFS) of the 5-ALA group compared to the white light group, as well as an observed increase in the OS and PFS of complete resections compared to incomplete resections. Of the studies that directly compared the use of 5-ALA to white light (13 of the total analyzed 45, or 28.9%), 5-ALA lead to a better PFS and OS in 88.4% and 67.5% of patients, respectively. When the studies that reported postoperative neurologic outcomes of surgeries using 5-ALA vs. white light were analyzed, 42.2% of subjects demonstrated 5-ALA use was associated with less post-op neurological deficits, whereas 34.5% demonstrated no statistically significant difference between 5-ALA and without. 23.3% of studies showed that intraoperative 5-ALA guided surgeries lead to more post-op neurological deficits. Conclusions and RelevanceUtilization of 5-ALA was found to be associated with a greater extent of resection in HGG surgeries, as well as longer OS and PFS. Postop neurologic deficit rates were mixed and inconclusive when comparing 5-ALA groups to white light groups. 5-ALA is a useful surgical adjunct for resection of HGG when patient safety is preserved.

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Minimally Invasive Resection of Deep-seated High-grade Gliomas Using Tubular Retractors and Exoscopic Visualization

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0038-1641738 ◽

2018 ◽

Vol 79 (04) ◽

pp. 330-336 ◽

Cited By ~ 16

Author(s):

Rajiv Iyer ◽

Kaisorn Chaichana

Keyword(s):

Minimally Invasive ◽

Hospital Stay ◽

Length Of Hospital Stay ◽

Extent Of Resection ◽

Karnofsky Performance Score ◽

High Grade ◽

Subcortical Structures ◽

Surgical Morbidity ◽

Tubular Retractor ◽

High Grade Gliomas

Background and Study Aims/Objective Deep-seated high-grade gliomas (HGGs) represent a unique surgical challenge because they reside deep to critical cortical and subcortical structures and infiltrate functional areas of the brain. Therefore, accessing and resecting these tumors can often be challenging and associated with significant morbidity. We describe the use of minimally invasive approaches to access deep-seated HGGs to achieve extensive resections while minimizing surgical morbidity. Materials and Methods All patients who underwent resection of a deep-seated intraparenchymal HGG with the use of a tubular retractor with exoscopic visualization from January 2016 to May 2017 were identified prospectively at a single institution. Variables evaluated included tumor location, pre- and postoperative neurologic function, extent of resection, and length of hospital stay. Results Overall, 14 patients underwent resection of an HGG (11 glioblastomas, 3 anaplastic astrocytomas) with a tubular retractor under exoscopic visualization. Seven tumors (50%) involved the thalamus, three (21%) the motor corticospinal tract, two (14%) the inferior frontal occipital fasciculus, one (7%) each the basal ganglia and optic pathway. The median preoperative Karnofsky Performance Score (KPS) was 70 (interquartile range: 55–80), where the major presenting symptom was motor weakness in seven (50%). The average plus or minus the standard error of the mean percentage resection was 97.0 ± 1.2%. The median hospital stay was 4 days (range: 2–7). At 1 month postoperatively, median postoperative KPS (within 30 days) was 87 (range: 77–90), where eight (57%) were improved, five (36%) were stable, and one (7%) was worse postoperatively. Conclusions Deep-seated HGGs can be accessed, visualized, and resected using tubular retractors and exoscopic visualization with minimal morbidity.

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Role of sentinel lymph node biopsy (SLNB) and preoperative MRI in the management of patients with pure high-grade ductal carcinoma in situ (DCIS).

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.26_suppl.87 ◽

2013 ◽

Vol 31 (26_suppl) ◽

pp. 87-87

Author(s):

Rajitha Sunkara ◽

Charu Taneja ◽

Dorcas Chi ◽

Gail Wolfe ◽

Christine Segal ◽

...

Keyword(s):

Sentinel Node ◽

Ductal Carcinoma ◽

Lymph Node Biopsy ◽

Low Grade ◽

High Grade ◽

Mri Findings ◽

Close Margin ◽

Surgical Morbidity ◽

Node Biopsy

87 Background: The overall incidence of SLN metastases in pure DCIS is < 1% and the results of SLNB do not usually impact treatment or survival but adds significant surgical morbidity. In addition, there is no evidence regarding the role of preoperative MRI in the management of DCIS. The purpose of our study was to identify the efficacy of SLNB and the benefit of preoperative MRI in high-grade DCIS. Methods: We performed retrospective review of 364 patients with DCIS, identified through our cancer registry database, that were seen from 2003 to 2012 at our institution. Of these, 62 patients were diagnosed with high-grade DCIS (Grade 3 or 2 with comedonecrosis) by core needle biopsy, and underwent SLNB. The remaining 302 patients had either low-grade DCIS or did not have a SLNB. Results: Median age was 56 years (range 33-80). Sixty two patients had high-grade DCIS on definitive excision and 2/62 patients were noted to have small invasive focus of disease. 15/62 (24.19%) patients underwent mastectomy and 47/62(78.1%) underwent lumpectomy. No patient had a positive SLN (0/62). 15/62 (24.2%) patients had breast MRI preoperatively and among them, in 5 (33.3%) patients, MRI findings changed the surgical decision to mastectomy. Among these 5 mastectomy patients, four of them (80%) had pathologically confirmed findings consistent with preoperative MRI suspicions. In lumpectomy patients, close margin of less than 1mm was seen in 4/9 (44.4%) patients with staging MRI and in 24/38 (63.15%) patients without MRI (p = 0.45. Fisher’s exact test). However the positive margin leading to re-excision was seen in 2/9 (22.2%) patients who underwent lumpectomy with staging MRI, and 9/38 (23.6%) patients who underwent lumpectomy without staging MRI. Conclusions: In our study, no patient with high grade DCIS had a positive sentinel node suggesting that routine sentinel node biopsy is not necessary in DCIS patients. The use of MRI changed the surgical planning in 33.3% of patients, but did not improve the surgeon's ability to achieve clear margins.

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Subtemporal Transtentorial Approach in Mesencephalic and Perimesencephalic Lesions in Children—A Series of 20 Patients

Operative Neurosurgery ◽

10.1093/ons/opz254 ◽

2019 ◽

Author(s):

Pietro Spennato ◽

Carmela Chiaramonte ◽

Carmela Russo ◽

Nicola Onorini ◽

Giuseppe Mirone ◽

...

Keyword(s):

Surgical Approach ◽

Neurological Deficits ◽

Direct Access ◽

Low Grade ◽

Superior Cerebellar Peduncle ◽

High Grade ◽

Subtemporal Approach ◽

Advantages And Disadvantages ◽

Neoplastic Lesions ◽

Surrounding Areas

Abstract BACKGROUND Midbrain and surrounding areas are among the most difficult regions to surgically approach in neurosurgery. The subtemporal approach is a well-known neurosurgical approach that is rarely described in children. OBJECTIVE To assess the feasibility, advantages, and disadvantages of subtemporal approach in children. METHODS A total of 20 pediatric patients with intra-axial tumors involving the lateral midbrain or superior cerebellar peduncle or with extra-axial tumors in the middle incisural space/Meckel cave underwent subtemporal transtentorial approaches with the aim to remove (16 cases) or biopsy (4 cases) their lesions. These cases were retrospectively reviewed and the surgical approach described. RESULTS Total resection was achieved in 11 patients. In the 4 patients who underwent biopsies, a diagnosis was obtained. A total of 5 patients presented non-neoplastic lesions (dermoid tumors or cavernomas). A total of 9 patients harbored low-grade tumors and 6 high-grade tumors. Patients with low-grade tumors and non-neoplastic lesions are all alive with no evidence of disease or stable residue. Four patients affected by high grade tumors died. No patient suffered permanent neurological deficits related to the surgical approach. Three patients presented temporary neurological deficits following the procedure: one case of strabismus, one case of aphasia and hemiparesis, secondary to delayed, transient thrombosis of the Labbé vein, and 1 case of trigeminal neuralgia. CONCLUSION The subtemporal approach represents a feasible approach for mesencephalic and perimesencephalic lesions in children. It provides an ample and direct access, with excellent outcomes and acceptable postoperative morbidity.

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The Use of 5-Aminolevulinic Acid in Low-Grade Glioma Resection: A Systematic Review

Operative Neurosurgery ◽

10.1093/ons/opz336 ◽

2019 ◽

Vol 19 (1) ◽

pp. 1-8

Author(s):

Ahmad Kareem Almekkawi ◽

Tarek Y El Ahmadieh ◽

Eva M Wu ◽

Abdullah M Abunimer ◽

Karl R Abi-Aad ◽

...

Keyword(s):

Systematic Review ◽

Quality Index ◽

Aminolevulinic Acid ◽

Extent Of Resection ◽

Low Grade Glioma ◽

Low Grade ◽

High Grade ◽

Patient Consent ◽

Visualization Technology ◽

Glioma Resection

Abstract BACKGROUND For optimizing high-grade glioma resection, 5-aminolevulinic acid is a reliable tool. However, its efficacy in low-grade glioma resection remains unclear. OBJECTIVE To study the role of 5-aminolevulinic acid in low-grade glioma resection and assess positive fluorescence rates and the effect on the extent of resection. METHODS A systematic review of PubMed, Google Scholar, and Cochrane was performed from the date of inception to February 1, 2019. Studies that correlated 5-aminolevulinic acid fluorescence with low-grade glioma in the setting of operative resection were selected. Studies with biopsy only were excluded. Positive fluorescence rates were calculated. The quality index of the selected papers was provided. No patient information was used, so Institutional Review Board approval and patient consent were not required. RESULTS A total of 12 articles met the selection criteria with 244 histologically confirmed low-grade glioma patients who underwent microsurgical resection. All patients received 20 mg/kg body weight of 5-aminolevulinic acid. Only 60 patients (n = 60/244; 24.5%) demonstrated visual intraoperative 5-aminolevulinic acid fluorescence. The extent of resection was reported in 4 studies; however, the data combined low- and high-grade tumors. Only 2 studies reported on tumor location. Only 3 studies reported on clinical outcomes. The Zeiss OPMI Pentero microscope was most commonly used across all studies. The average quality index was 14.58 (range: 10-17), which correlated with an overall good quality. CONCLUSION There is an overall low correlation between 5-aminolevulinic acid fluorescence and low-grade glioma. Advances in visualization technology and using standardized fluorescence quantification methods may further improve the visualization and reliability of 5-aminolevulinic acid fluorescence in low-grade glioma resection.

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Magnetic resonance–guided stereotactic laser ablation therapy for the treatment of pediatric brain tumors: a multiinstitutional retrospective study

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.1.peds19496 ◽

2020 ◽

Vol 26 (1) ◽

pp. 13-21

Author(s):

Elsa V. Arocho-Quinones ◽

Sean M. Lew ◽

Michael H. Handler ◽

Zulma Tovar-Spinoza ◽

Matthew Smyth ◽

...

Keyword(s):

Laser Ablation ◽

Brain Tumors ◽

Adjuvant Treatment ◽

Pediatric Brain Tumors ◽

Tumor Location ◽

Neurological Deficits ◽

Low Grade ◽

High Grade ◽

Pediatric Brain

OBJECTIVEThis study aimed to assess the safety and efficacy of MR-guided stereotactic laser ablation (SLA) therapy in the treatment of pediatric brain tumors.METHODSData from 17 North American centers were retrospectively reviewed. Clinical, technical, and radiographic data for pediatric patients treated with SLA for a diagnosis of brain tumor from 2008 to 2016 were collected and analyzed.RESULTSA total of 86 patients (mean age 12.2 ± 4.5 years) with 76 low-grade (I or II) and 10 high-grade (III or IV) tumors were included. Tumor location included lobar (38.4%), deep (45.3%), and cerebellar (16.3%) compartments. The mean follow-up time was 24 months (median 18 months, range 3–72 months). At the last follow-up, the volume of SLA-treated tumors had decreased in 80.6% of patients with follow-up data. Patients with high-grade tumors were more likely to have an unchanged or larger tumor size after SLA treatment than those with low-grade tumors (OR 7.49, p = 0.0364). Subsequent surgery and adjuvant treatment were not required after SLA treatment in 90.4% and 86.7% of patients, respectively. Patients with high-grade tumors were more likely to receive subsequent surgery (OR 2.25, p = 0.4957) and adjuvant treatment (OR 3.77, p = 0.1711) after SLA therapy, without reaching significance. A total of 29 acute complications in 23 patients were reported and included malpositioned catheters (n = 3), intracranial hemorrhages (n = 2), transient neurological deficits (n = 11), permanent neurological deficits (n = 5), symptomatic perilesional edema (n = 2), hydrocephalus (n = 4), and death (n = 2). On long-term follow-up, 3 patients were reported to have worsened neuropsychological test results. Pre-SLA tumor volume, tumor location, number of laser trajectories, and number of lesions created did not result in a significantly increased risk of complications; however, the odds of complications increased by 14% (OR 1.14, p = 0.0159) with every 1-cm3 increase in the volume of the lesion created.CONCLUSIONSSLA is an effective, minimally invasive treatment option for pediatric brain tumors, although it is not without risks. Limiting the volume of the generated thermal lesion may help decrease the incidence of complications.

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Short-term Complications Associated With Surgery for High-Grade Spondylolisthesis in Adults and Pediatric Patients

Neurosurgery ◽

10.1227/neu.0b013e3182535881 ◽

2012 ◽

Vol 71 (1) ◽

pp. 109-116 ◽

Cited By ~ 32

Author(s):

Manish K. Kasliwal ◽

Justin S. Smith ◽

Christopher I. Shaffrey ◽

Dwight Saulle ◽

Lawrence G. Lenke ◽

...

Keyword(s):

Surgical Treatment ◽

Pediatric Patients ◽

Case Reports ◽

Case Series ◽

Adult Patients ◽

Neurological Deficits ◽

Low Grade ◽

Complication Rates ◽

High Grade ◽

Short Term

Abstract BACKGROUND: Although it is generally agreed upon that surgery for high-grade spondylolisthesis (HGS) is associated with more complications than low-grade spondylolisthesis, its description is primarily based on case reports and relatively small case series. OBJECTIVE: To assess short-term complication rates associated with the surgical treatment of HGS in pediatric and adult patients and to identify factors associated with increased complication rates. METHODS: All cases of HGS from the Scoliosis Research Society Morbidity and Mortality database for the year 2007 were reviewed. Patients were classified as pediatric (⩽18 years) or adult (>18 years). Complications were tabulated, and the rates were compared between the patient groups and based on clinical and surgical factors. RESULTS: 165 cases of HGS were reported (88 pediatric, 77 adult). There were 49 complications (29.7%) in 41 patients (24.8%), with no difference in the proportions of pediatric vs adult patients with a complication (P = .86). Occurrence of new neurological deficit after surgery was the most common complication, seen in 19 (11.5%) patients. Performance of an osteotomy was associated with a higher incidence of new neurological deficits in both adult and pediatric groups (P = .02 and P = .012, respectively). Although most of the new neurological deficits improved over follow-up, 10% had no improvement. CONCLUSION: This study provides short-term complication rates associated with surgical treatment for HGS in adult and pediatric patients and may prove valuable for patient counseling, surgical planning, and in efforts to improve the safety of patient care.

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SURG-04. INTRAOPERATIVE HAND-HELD LINE-SCANNED DUAL-AXIS CONFOCAL MICROSCOPY FOR VISUALIZING LOW-GRADE GLIOMAS

Neuro-Oncology ◽

10.1093/neuonc/noz175.1005 ◽

2019 ◽

Vol 21 (Supplement_6) ◽

pp. vi240-vi240

Author(s):

Yoko Fujita ◽

Linpeng Wei ◽

Jonathan T C Liu ◽

Nader Sanai

Keyword(s):

Confocal Microscopy ◽

Normal Tissue ◽

Ex Vivo ◽

Motion Artifact ◽

Extent Of Resection ◽

Confocal Microscope ◽

Low Grade Glioma ◽

Low Grade ◽

High Grade ◽

Glioma Tissue

Abstract BACKGROUND Extent of resection is a prognostic factor for low- and high-grade gliomas. Fluorescence guided surgery (FGS) using five-aminolevulinic acid (5-ALA) is associated with greater extent of resection in high-grade gliomas. However, for low-grade gliomas, intraoperative imaging technologies such as FGS, have not been optimized to distinguish tumor from normal tissue. Intraoperative confocal microscopy can better visualize tissue cytoarchitecture in real-time. Here we report on the feasibility of a newly-developed, hand-held, line-scanned dual-axis (LS-DAC) confocal microscope in distinguishing tumor vs. normal cells in ex vivo human low-grade glioma tissue. METHOD Ten low-grade glioma patients who underwent craniotomy were enrolled. Resected specimens were labelled with acridine orange (1mM) for one minute, and exposed surfaces were immediately imaged by our device. Subsequently, specimens were cut into sections and stained with H&E for histopathological analysis. RESULTS LS-DAC confocal microscope visualized nuclei of tumor cells vs. surrounding tissue, demonstrating clear differences in cellularity in the two compartments. Acquired images were comparable to those observed on matched H&E-stained sections. Live images provided minimal motion artifact due to the higher frame rate of 16 Hz. CONCLUSION LS-DAC confocal microscope provided real-time, high-contrast mosaic images of human low-grade glioma tissue ex vivo. The ability to distinguish tumor vs. normal tissue at the cellular level with little motion artifact, as well as the device’s hand-held design, suggests this technology merits additional investigation as an intraoperative adjunct for low-grade glioma surgery.

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