Awake Surgery for Left Posterior Insular Low-Grade Glioma Through the Parietorolandic Operculum: The Need to Preserve the Functional Connectivity. A Case Series

Frontiers in Surgery ◽

10.3389/fsurg.2021.824003 ◽

2022 ◽

Vol 8 ◽

Author(s):

Hugues Duffau

Keyword(s):

White Matter ◽

Functional Connectivity ◽

Case Series ◽

Low Grade Glioma ◽

Awake Surgery ◽

Cortical Mapping ◽

Lateral Part ◽

Low Grade ◽

Left Posterior ◽

Transcortical Approach

Objective: Surgical approach to low-grade glioma (LGG) involving the posterior insula is challenging, especially in the left hemisphere, with a high risk of sensorimotor, language, or visual deterioration. In this study, a case series of 5 right-handed patients harboring a left posterior insular LGG is reported, by detailing a transcorticosubcortical approach.Method: The five surgeries were achieved in awake patients using cortical and axonal electrostimulation mapping. The glioma was removed through the left rolandic and/or parietal opercula, with preservation of the subcortical connectivity.Results: The cortical mapping was positive in the five patients, enabling the selection of an optimal transcortical approach, via the anterolateral supramarginal gyrus in four patients and/or via the lateral retrocentral gyrus in three cases (plus through the left superior temporal gyrus in one case). Moreover, the white matter tracts were identified in all cases, i.e., the lateral part of the superior longitudinal fasciculus (five cases), the arcuate fasciculus (four cases), the thalamocortical somatosensory pathways (four cases), the motor pathway (one case), the semantic pathway (three cases), and the optic tract (one case). Complete resection of the LGG was achieved in two patients and near-total resection in three patients. There were no postoperative permanent sensorimotor, language, or visual deficits.Conclusion: A transcortical approach through the parietorolandic operculum in awake patients represents safe and effective access to the left posterior insular LGG. Detection and preservation of the functional connectivity using direct electrostimulation of the white matter bundles are needed in this cross-road brain region to prevent otherwise predictable postsurgical impairments.

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Changes in language white matter tract microarchitecture associated with cognitive deficits in patients with presumed low-grade glioma

Journal of Neurosurgery ◽

10.3171/2017.12.jns171681 ◽

2019 ◽

Vol 130 (5) ◽

pp. 1538-1546 ◽

Cited By ~ 6

Author(s):

Fatih Incekara ◽

Djaina Satoer ◽

Evy Visch-Brink ◽

Arnaud Vincent ◽

Marion Smits

Keyword(s):

Executive Function ◽

Diffusion Tensor Imaging ◽

White Matter ◽

Diffusion Tensor ◽

Mean Diffusivity ◽

Low Grade Glioma ◽

Cognitive Domain ◽

Awake Surgery ◽

Low Grade ◽

Linear Regression Models

OBJECTIVEThe authors conducted a study to determine whether cognitive functioning of patients with presumed low-grade glioma is associated with white matter (WM) tract changes.METHODSThe authors included 77 patients with presumed low-grade glioma who underwent awake surgery between 2005 and 2013. Diffusion tensor imaging with deterministic tractography was performed preoperatively to identify the arcuate, inferior frontooccipital, and uncinate fasciculi and to obtain the mean fractional anisotropy (FA) and mean diffusivity per tract. All patients were evaluated preoperatively using an extensive neuropsychological protocol that included assessments of the language, memory, and attention/executive function domains. Linear regression models were used to analyze each cognitive domain and each diffusion tensor imaging metric of the 3 WM tracts.RESULTSSignificant correlations (corrected for multiple testing) were found between FA of the arcuate fasciculus and results of the repetition test for the language domain (β = 0.59, p < 0.0001) and between FA of the inferior frontooccipital fasciculus and results of the imprinting test for the memory domain (β = −0.55, p = 0.002) and the attention test for the attention and executive function domain (β = −0.62, p = 0.006).CONCLUSIONSIn patients with glioma, language deficits in repetition of speech, imprinting, and attention deficits are associated with changes in the microarchitecture of the arcuate and inferior frontooccipital fasciculi.

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Awake mapping for low-grade gliomas involving the left sagittal stratum: anatomofunctional and surgical considerations

Journal of Neurosurgery ◽

10.3171/2014.1.jns132015 ◽

2014 ◽

Vol 120 (5) ◽

pp. 1069-1077 ◽

Cited By ~ 30

Author(s):

Emilie Chan-Seng ◽

Sylvie Moritz-Gasser ◽

Hugues Duffau

Keyword(s):

Quality Of Life ◽

White Matter ◽

Functional Anatomy ◽

Awake Surgery ◽

Cortical Mapping ◽

Subtotal Resection ◽

Low Grade ◽

Temporal Part ◽

Who Grade

Object Preserving function while optimizing the extent of resection is the main goal in surgery for diffuse low-grade glioma (DLGG). This is particularly relevant for DLGG involving the sagittal stratum (SS), where damage can have severe consequences. Indeed, this structure is a major crossroad in which several important fascicles run. Thus, its complex functional anatomy is still poorly understood. Subcortical electrical stimulation during awake surgery provides a unique opportunity to investigate white matter pathways. This study reports the findings on anatomofunctional correlations evoked by stimulation during resection for gliomas involving the left SS. Surgical outcomes are also detailed. Methods The authors performed a review of patients who underwent awake surgery for histopathologically confirmed WHO Grade II glioma involving the left SS in the neurosurgery department between August 2008 and August 2012. Information regarding clinicoradiological features, surgical procedures, and outcomes was collected and analyzed. Intraoperative electrostimulation was used to map the eloquent structures within the SS. Results Eight consecutive patients were included in this study. There were 6 men and 2 women, whose mean age was 41.7 years (range 32–61 years). Diagnosis was made because of seizures in 7 cases and slight language disorders in 1 case. After cortical mapping, subcortical stimulation detected functional fibers running in the SS in all patients: semantic paraphasia was generated by stimulating the inferior frontooccipital fascicle in 8 cases; alexia was elicited by stimulating the inferior longitudinal fascicle in 3 cases; visual disorders were induced by stimulating the optic radiations in 5 cases. Moreover, in front of the SS, phonemic paraphasia was evoked by stimulating the temporal part of the arcuate fascicle in 5 patients. The resection was stopped according to these functional limits in the 8 patients. After a transient postsurgical worsening, all patients recovered to normal results on examination, except for the persistence of a right superior quadrantanopia in 5 cases, with no consequences for quality of life. The 8 patients returned to a normal social and professional life. Total or subtotal resection was achieved in all cases but one. Conclusions The authors suggest that the use of intrasurgical electrical mapping of the white matter pathways in awake patients opens the door to extensive resection of DLGG within the left SS while preserving the quality of life. Further anatomical, clinical, radiological, and electrophysiological studies are needed for a better understanding of the functional anatomy of this complex region.

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Patterns of Interaction Between Diffuse Low-Grade Glioma and Pregnancy: An Institutional Case Series

World Neurosurgery ◽

10.1016/j.wneu.2021.02.136 ◽

2021 ◽

Author(s):

Vasileios K. Kavouridis ◽

Paola Calvachi ◽

Charles H. Cho ◽

Timothy R. Smith

Keyword(s):

Case Series ◽

Low Grade Glioma ◽

Low Grade ◽

Patterns Of Interaction

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Anesthesia management for low-grade glioma awake surgery: a European Low-Grade Glioma Network survey

Acta Neurochirurgica ◽

10.1007/s00701-020-04274-0 ◽

2020 ◽

Vol 162 (7) ◽

pp. 1701-1707 ◽

Cited By ~ 3

Author(s):

Jeremy Arzoine ◽

◽

Charlotte Levé ◽

Antonio Pérez-Hick ◽

John Goodden ◽

...

Keyword(s):

Low Grade Glioma ◽

Awake Surgery ◽

Low Grade ◽

Anesthesia Management

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P14.27 The significance of multicentric noncontrast-enhancing lesions distant from surgically resected glioblastoma: Case series of 3 patients

Neuro-Oncology ◽

10.1093/neuonc/noz126.262 ◽

2019 ◽

Vol 21 (Supplement_3) ◽

pp. iii72-iii73

Author(s):

J Hwang ◽

H An ◽

S Yoon ◽

K Park

Keyword(s):

Temporal Lobe ◽

Multidisciplinary Treatment ◽

Case Series ◽

Tumor Location ◽

Low Grade Glioma ◽

Low Grade ◽

Post Contrast ◽

Poor Prognostic Factor ◽

Prognostic Features ◽

18Fdg Pet

Abstract BACKGROUND Glioblastoma is the most malignant primary brain tumor. The tumor location and multiplicity plays an important role in surgical and further treatment. The incidence of multiple lesions at the time of diagnosis was known as 1–20%, which showed a poor prognostic factor. Most researches has focused on multiple contrast-enhancing lesions, however, multicentric non-enhancing lesions distant from glioblastoma has been rarely evaluated. The authors reported the case series of the patient who showed multicentric non contrast-enhancing lesions without connection to histologically-proven glioblastoma. MATERIAL AND METHODS Multicentric non contrast-enhancing lesions were defined as areas of FLAIR hyperintensity and mass effect without post-contrast enhancement, separated from the histologically-proven glioblastoma in a newly diagnosed disease. Three patients who showed distant non-enhancing lesions with appearance of a multicentric low-grade glioma were included in this study. The typical enhancing lesions were surgically resected and standard chemo-radiotherapy was followed in all patients. RESULTS All patients were male and their age was 38, 60 and 65 years old respectively. Multicentric tumor location was as follows: Case 1, left frontal lobe with non-enhancing lesion in left parahippocampal gyrus; Case 2, left parietal with non-enhancing lesion in left anteromedial temporal lobe; Case 3, left thalamus with non-enhancing lesions in both basal frontal and right temporal lobe. Pathologically, the resected enhancing tumor revealed glioblastoma in 2 patients and diffuse midline glioma in 1. All tumors were IDH-wild type. The resected enhanced lesion showed no progression but all non-enhancing lesions developed contrast-enhancing tumors at 3, 13 and 17 months after initial treatment, with high tracer uptake on 18FDG-PET or 18FDOPA-PET. Despite multidisciplinary treatment, two patients died from disease progression at 30 and 32 months after diagnosis and one patient is still alive with overall survival of 15 months. CONCLUSION The appearance of multicentric non-enhancing lesions distant from a typically enhancing tumor showed an uncommon finding in glioblastoma and poor prognostic features. These lesions progress faster than expected for a low-grade glioma. These lesions should be distinguished from typical low-grade glioma and should be considered more advanced lesions than their appearances suggest.

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Intraoperative electrical stimulation in awake craniotomy: methodological aspects of current practice

Neurosurgical FOCUS ◽

10.3171/2009.12.focus09237 ◽

2010 ◽

Vol 28 (2) ◽

pp. E7 ◽

Cited By ~ 186

Author(s):

Andrea Szelényi ◽

Lorenzo Bello ◽

Hugues Duffau ◽

Enrica Fava ◽

Guenther C. Feigl ◽

...

Keyword(s):

Electrical Stimulation ◽

Cognitive Function ◽

Low Grade Glioma ◽

Awake Craniotomy ◽

Awake Surgery ◽

Low Grade ◽

Glioma Surgery ◽

Neurological Sequelae ◽

Intraoperative Electrical Stimulation ◽

Methodological Aspects

There is increasing evidence that the extent of tumor removal in low-grade glioma surgery is related to patient survival time. Thus, the goal of resecting the largest amount of tumor possible without leading to permanent neurological sequelae is a challenge for the neurosurgeon. Electrical stimulation of the brain to detect cortical and axonal areas involved in motor, language, and cognitive function and located within the tumor or along its boundaries has become an essential tool in combination with awake craniotomy. Based on a literature review, discussions within the European Low-Grade Glioma Group, and illustrative clinical experience, the authors of this paper provide an overview for neurosurgeons, neurophysiologists, linguists, and anesthesiologists as well as those new to the field about the stimulation techniques currently being used for mapping sensorimotor, language, and cognitive function in awake surgery for low-grade glioma. The paper is intended to help the understanding of these techniques and facilitate a comparison of results between users.

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Awake Mapping Optimizes the Extent of Resection for Low-Grade Gliomas in Eloquent Areas

Neurosurgery ◽

10.1227/01.neu.0000369514.74284.78 ◽

2010 ◽

Vol 66 (6) ◽

pp. 1074-1084 ◽

Cited By ~ 149

Author(s):

Alessandro De Benedictis ◽

Sylvie Moritz-Gasser ◽

Hugues Duffau

Keyword(s):

Extent Of Resection ◽

Low Grade Glioma ◽

Awake Surgery ◽

Low Grade ◽

Functional Sites ◽

Social Lives ◽

Eloquent Areas ◽

Functional Regions ◽

First Time

Abstract BACKGROUND Awake craniotomy with intraoperative electrical mapping is a reliable method to minimize the risk of permanent deficit during surgery for low-grade glioma located within eloquent areas classically considered inoperable. However, it could be argued that preservation of functional sites might lead to a lesser degree of tumor removal. To the best of our knowledge, the extent of resection has never been directly compared between traditional and awake procedures. OBJECTIVE We report for the first time a series of patients who underwent 2 consecutive surgeries without and with awake mapping. METHODS Nine patients underwent surgery for a low-grade glioma in functional sites under general anesthesia in other institutions. The resection was subtotal in 3 cases and partial in 6 cases. There was a postoperative worsening in 3 cases. We performed a second surgery in the awake condition with intraoperative electrostimulation. The resection was performed according to functional boundaries at both the cortical and subcortical levels. RESULTS Postoperative magnetic resonance imaging showed that the resection was complete in 5 cases and subtotal in 4 cases (no partial removal) and that it was improved in all cases compared with the first surgery (P = .04). There was no permanent neurological worsening. Three patients improved compared with the presurgical status. All patients returned to normal professional and social lives. CONCLUSION Our results demonstrate that awake surgery, known to preserve the quality of life in patients with low-grade glioma, is also able to significantly improve the extent of resection for lesions located in functional regions.

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