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Gravesteijn BY, Keizer ME, Vincent AJPE, Schouten JW, Stolker RJ, Klimek M. Awake craniotomy versus craniotomy under general anesthesia for the surgical treatment of insular glioma: choices and outcomes. Neurol Res 2017; 40:87-96. [DOI: 10.1080/01616412.2017.1402147] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- B. Y. Gravesteijn
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - M. E. Keizer
- Department of Neurosurgery, Erasmus MC, Rotterdam, The Netherlands
| | | | - J. W. Schouten
- Department of Neurosurgery, Erasmus MC, Rotterdam, The Netherlands
| | - R. J. Stolker
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - M. Klimek
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
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Volumetric Analysis of Extent of Resection, Survival, and Surgical Outcomes for Insular Gliomas. World Neurosurg 2017; 103:265-274. [DOI: 10.1016/j.wneu.2017.04.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/30/2017] [Accepted: 04/01/2017] [Indexed: 12/20/2022]
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Ikegaya N, Takahashi A, Kaido T, Kaneko Y, Iwasaki M, Kawahara N, Otsuki T. Surgical strategy to avoid ischemic complications of the pyramidal tract in resective epilepsy surgery of the insula: technical case report. J Neurosurg 2017; 128:1173-1177. [PMID: 28598277 DOI: 10.3171/2017.1.jns161278] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Surgical treatment of the insula is notorious for its high probability of motor complications, particularly when resecting the superoposterior part. Ischemic damage to the pyramidal tract in the corona radiata has been regarded as the cause of these complications, resulting from occlusion of the perforating arteries to the pyramidal tract through the insular cortex. The authors describe a strategy in which a small piece of gray matter is spared at the bottom of the periinsular sulcus, where the perforating arteries pass en route to the pyramidal tract, in order to avoid these complications. This method was successfully applied in 3 patients harboring focal cortical dysplasia in the posterior insula and frontoparietal operculum surrounding the periinsular sulcus. None of the patients developed permanent postoperative motor deficits, and seizure control was achieved in all 3 cases. The method described in this paper can be adopted for functional preservation of the pyramidal tract in the corona radiata when resecting epileptogenic pathologies involving insular and opercular regions.
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Affiliation(s)
- Naoki Ikegaya
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira.,2Department of Neurosurgery, Yokohama City University, Yokohama; and
| | - Akio Takahashi
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira
| | - Takanobu Kaido
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira
| | - Yuu Kaneko
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira
| | - Masaki Iwasaki
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira
| | - Nobutaka Kawahara
- 2Department of Neurosurgery, Yokohama City University, Yokohama; and
| | - Taisuke Otsuki
- 1Department of Neurosurgery, Epilepsy Center, National Center of Neurology and Psychiatry (NCNP), Kodaira.,3Epilepsy Hospital Bethel Japan, Iwanuma, Japan
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Murrone D, Maduri R, Afif A, Chirchiglia D, Pelissou-Guyotat I, Guyotat J, Signorelli F. Insular gliomas: a surgical reappraisal based on a systematic review of the literature. J Neurosurg Sci 2017; 63:566-580. [PMID: 28548479 DOI: 10.23736/s0390-5616.17.04045-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Insular gliomas are heterogeneous lesions whose management presents multiple challenges for their tendency to affect young patients in good neurological and cognitive conditions, their deep anatomic location and proximity with critical functional and vascular structures. The appropriate management of insular gliomas requires a multidisciplinary evidence-centred teamwork grounded on the best anatomic, neurophysiological and oncological knowledge. The present study provides a reappraisal of the management of insular gliomas based on a systematic review of the literature with the aim of guiding clinicians in the management of such tumors. EVIDENCE ACQUISITION A systematic review of the literature from the Medline, Embase and Cochrane Central databases was performed. From 2006 to 2016, all articles meeting specific inclusion criteria were included. EVIDENCE SYNTHESIS The present work summarizes the most relevant evidence about insular gliomas management. The anatomy and physiology of the insula, the new WHO 2016 classification and clinico-radiological presentation of insular gliomas are reviewed. Surgical pearls of insular gliomas resection as well as oncologic and functional outcomes after insular gliomas treatment are discussed. CONCLUSIONS Management of insular gliomas remains challenging despite improvement in surgical and oncological techniques. However, the literature review supports a growing evidence that recent developments in the multidisciplinary care account for constant improvements of survival and quality of life.
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Affiliation(s)
- Domenico Murrone
- Service of Neurosurgery, "Di Venere" Hospital of Bari, Bari, Italy
| | - Rodolfo Maduri
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Afif Afif
- Service of Neurosurgery A, "Pierre Wertheimer" Neurological Neurosurgical Hospital of Lyon, Lyon, France
| | - Domenico Chirchiglia
- Department of Medical Sciences, "Magna Græcia" University of Catanzaro, Catanzaro, Italy
| | - Isabelle Pelissou-Guyotat
- Service of Neurosurgery A, "Pierre Wertheimer" Neurological Neurosurgical Hospital of Lyon, Lyon, France
| | - Jacques Guyotat
- Service of Neurosurgery A, "Pierre Wertheimer" Neurological Neurosurgical Hospital of Lyon, Lyon, France
| | - Francesco Signorelli
- Department of Basic Medical Sciences, Neurosciences and Sense Organs "Aldo Moro" University, Bari, Italy -
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Deng L, Zhou H, Xiao B, Bai HX, Yang L. Letter to the Editor. Specificity and validity of putaminal involvement as a prognostic factor in Grade II insular gliomas. J Neurosurg 2017; 126:2053-2054. [PMID: 28186455 DOI: 10.3171/2016.9.jns162311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lu Deng
- The First Xiangya Hospital, Central South University, Changsha, Hunan, China;
- Hospital of the University of Pennsylvania, Philadelphia, PA; and
- The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hao Zhou
- The First Xiangya Hospital, Central South University, Changsha, Hunan, China;
- Hospital of the University of Pennsylvania, Philadelphia, PA; and
- The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Bo Xiao
- The First Xiangya Hospital, Central South University, Changsha, Hunan, China;
- Hospital of the University of Pennsylvania, Philadelphia, PA; and
- The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Harrison X. Bai
- The First Xiangya Hospital, Central South University, Changsha, Hunan, China;
- Hospital of the University of Pennsylvania, Philadelphia, PA; and
- The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Li Yang
- The First Xiangya Hospital, Central South University, Changsha, Hunan, China;
- Hospital of the University of Pennsylvania, Philadelphia, PA; and
- The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
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Panigrahi M, Chandrasekhar YBVK, Vooturi S, Ram GA, Rammohan VSV. Surgical Resection of Insular Gliomas and Roles of Functional Magnetic Resonance Imaging and Diffusion Tensor Imaging Tractography-Single Surgeon Experience. World Neurosurg 2016; 98:587-593. [PMID: 27838429 DOI: 10.1016/j.wneu.2016.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/31/2016] [Accepted: 11/01/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In gliomas located in proximity to eloquent areas, near total resection and subsequent radiotherapy is often preferred to avoid postoperative neurologic complications. Preoperative functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) tractography provide new insights into surgeries of insular gliomas. In this study we report our experience of surgical management of insular gliomas and the role of fMRI and DTI tractography in planning the resection. METHODS We retrospectively compared the clinical and outcome variables of 61 patients who underwent surgical resection of insular gliomas. The study population was divided into 2 groups according to the use of fMRI and DTI tractography in planning the resection. RESULTS The average age of the study population was 44.1 ± 12.6 years with 21 (34.4%) of the patients women. Nearly two thirds of them (40, or 65.6%) had World Health Organization grade II tumors, and 16 patients (26.2%) had grade IV tumors. The most common tumor was glioblastoma, observed in 16 patients (26.2%). In 10 (16.4%) patients, fMRI and DTI tractography were used. The overall mortality in the study population was 15 (24.6%). None of the patients where fMRI and DTI were used for planning the surgery died (29.4% vs. 0.0%; P = 0.05), and all of them had normal functioning (70.5% vs. 100.0%; P = 0.05) at 3 months' follow-up. CONCLUSION Surgical resection of insular gliomas remains a challenge to the neurosurgeon and demands good knowledge of anatomic landmarks. Use of fMRI and DTI tractography may help achieve a good outcome.
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Affiliation(s)
- Manas Panigrahi
- Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India.
| | - Y B V K Chandrasekhar
- Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
| | - Sudhindra Vooturi
- Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
| | - G Ananta Ram
- Department of Radiology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
| | - V S V Rammohan
- Department of Radiology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
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Mandonnet E, Martino J, Sarubbo S, Corrivetti F, Bouazza S, Bresson D, Duffau H, Froelich S. Neuronavigated Fiber Dissection with Pial Preservation: Laboratory Model to Simulate Opercular Approaches to Insular Tumors. World Neurosurg 2016; 98:239-242. [PMID: 27765721 DOI: 10.1016/j.wneu.2016.10.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/01/2016] [Accepted: 10/04/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Advances in the oncologic and functional results of insular surgery have been reported recently. Such successes have been made possible by the advent of the transopercular approach under awake monitoring and by improved anatomic and functional knowledge of white matter pathways surrounding the insula. Nonetheless, given the rarity of insular tumors, it is difficult to get familiar with the complex 3-dimensional anatomy of the different neuronal and vascular structures encountered during a transopercular insular resection. We thus propose to develop a laboratory model allowing to train transopercular approaches of the insula. METHODS Two hemispheres prepared with Klinger's technique were dissected under light microscope, preserving all pial membranes. The different steps of the dissection were video recorded. RESULTS Preservation of pial membranes enabled us to simulate subpial resection, both during operculum removal and during insular cortex resection. The medial wall of the resection was defined by the inferior-fronto-occipital fasciculus, protecting from the lenticulostriate arteries. CONCLUSION In this paper, we show that Klinger dissection with preservation of pial membranes provides a realistic model of insular surgery, allowing surgeons to learn and train on this highly specialized surgery.
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Affiliation(s)
- Emmanuel Mandonnet
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France; University Paris 7, Paris, France; IMNC UMR8165, Orsay, France.
| | - Juan Martino
- Department of Neurological Surgery, Hospital Universitario Marques de Valdecilla and Fundacion Instituto de Investigacion Marques de Valdecilla (IDIVAL), Trento APSS, Italy
| | - Silvio Sarubbo
- Department of Neurosciences, Division of Neurosurgery, Structural and Functional Connectivity Lab Project, 'S. Chiara' Hospital, Trento APSS, Italy; Structural and Functional Connectivity Lab Project, Division of Neurosurgery, 'S. Chiara' Hospital, Trento APSS, Italy
| | - Francesco Corrivetti
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France; Department of Neurosurgery, University of Rome Tor Vergata, Rome, Italy
| | | | - Damien Bresson
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France
| | - Hugues Duffau
- Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier Medical University Center, Montpellier, France; Institute of Neuroscience of Montpellier, INSERM U1051, Montpellier, France
| | - Sebastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, APHP, Paris, France; University Paris 7, Paris, France; Laboratory of Experimental Neurosurgery, Paris, France
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Gras-Combe G, Minotti L, Hoffmann D, Krainik A, Kahane P, Chabardes S. Surgery for Nontumoral Insular Epilepsy Explored by Stereoelectroencephalography. Neurosurgery 2016; 79:578-88. [DOI: 10.1227/neu.0000000000001257] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Hidden by the perisylvian operculi, insular cortex has long been underexplored in the context of epilepsy surgery. Recent studies advocated stereoelectroencephalography (SEEG) as a reliable tool to explore insular cortex and its involvement in intractable epilepsy and suggested that insular seizures could be an underestimated entity. However, the results of insular resection to treat pharmacoresistant epilepsy are rarely reported.
OBJECTIVE
We report 6 consecutive cases of right insular resection performed based on anatomoelectroclinical correlations provided by SEEG.
METHODS
Six right-handed patients (3 male, 3 female) with drug-resistant epilepsy underwent comprehensive presurgical evaluation. Based on video electroencephalographic recordings, they all underwent SEEG evaluation with bilateral (n = 4) or unilateral right (n = 2) insular depth electrode placement. All patients had both orthogonal and oblique (1 anterior, 1 posterior) insular electrodes (n = 4-6 electrodes). Preoperative magnetic resonance imaging findings were normal in 4 patients, 1 patient had right insular focal cortical dysplasia, and 1 patient had a right opercular postoperative scar (cavernous angioma). All patients underwent right partial insular corticectomy via the subpial transopercular approach.
RESULTS
Intracerebral recordings demonstrated an epileptogenic zone confined to the right insula in all patients. After selective insular resection, 5 of 6 patients were seizure free (Engel class I) with a mean follow-up of 36.2 months (range, 18-68 months). Histological findings revealed focal cortical dysplasia in 5 patients and a gliosis scar in 1 patient. All patients had minor transient neurological deficit (eg, facial paresis, dysarthria).
CONCLUSION
Insular resection based on SEEG findings can be performed safely with a significant chance of seizure freedom.
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Affiliation(s)
- Guillaume Gras-Combe
- INSERM U1216, Grenoble Institut des Neurosciences, Grenoble, France
- Département de Neurochirurgie, Hôpital Gui de Chauliac, Centre Hospitalier Universitaire, Montpellier, France
| | - Lorella Minotti
- Clinique de Neurologie, Centre Hospitalier Universitaire, Grenoble, France
| | - Dominique Hoffmann
- Clinique de Neurochirurgie, Centre Hospitalier Universitaire, Grenoble, France
| | - Alexandre Krainik
- Clinique de Neurochirurgie, Centre Hospitalier Universitaire, Grenoble, France
- Clinique de Neuroradiologie, Centre Hospitalier Universitaire, Grenoble, France
- University Grenoble Alpes, Grenoble, France
| | - Philippe Kahane
- INSERM U1216, Grenoble Institut des Neurosciences, Grenoble, France
- Clinique de Neurochirurgie, Centre Hospitalier Universitaire, Grenoble, France
- University Grenoble Alpes, Grenoble, France
| | - Stephan Chabardes
- INSERM U1216, Grenoble Institut des Neurosciences, Grenoble, France
- Clinique de Neuroradiologie, Centre Hospitalier Universitaire, Grenoble, France
- University Grenoble Alpes, Grenoble, France
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Clinical considerations and surgical approaches for low-grade gliomas in deep hemispheric locations: insular lesions. Childs Nerv Syst 2016; 32:1875-93. [PMID: 27659830 DOI: 10.1007/s00381-016-3183-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 07/06/2016] [Indexed: 12/31/2022]
Abstract
Insula and paralimbic region represent a common location for gliomas in adulthood. However, limbic and paralimbic tumors are rare in children. Reports of pediatric insular tumors are scarce in literature, and most of them are included in adult's series, so their management and outcome can be outlined only after extracting data from these reports. Due to their predominantly low grade, they usually have a benign course for some time, what make them ideal candidates for total resection. However, their intricate location and spread to key areas, including the temporal lobe, make them a surgical challenge. The transsylvian route, with or without resection of the frontal and/or temporal operculae, which requires exposure of part or all of the insula is commonly selected for insular tumor approaches. Intraoperative functional mapping is a standard procedure for resection of central region tumors in adults. In children and young individuals, awake craniotomy is not always possible and surgical planning usually relay on functional and anatomical preoperative studies. The main goal when approaching an insular tumor is to achieve the largest extent of resection to increase overall patient survival while preserving the functional status, minimizing postoperative morbidity and increasing the quality of life. The extent of resection seems to be correlated also with the control of associated (and usually intractable) epilepsy.
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The transsylvian approach for resection of insular gliomas: technical nuances of splitting the Sylvian fissure. J Neurooncol 2016; 130:283-287. [PMID: 27294356 DOI: 10.1007/s11060-016-2154-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/26/2016] [Indexed: 12/19/2022]
Abstract
Insular gliomas represent a unique surgical challenge due to the complex anatomy and nearby vascular elements associated within the Sylvian fissure. For certain tumors, the transsylvian approach provides an effective technique for achieving maximal safe resection. The goal of this manuscript and video are to present and discuss the surgical nuances and appropriate application of splitting the Sylvian fissure. Our hope is that this video highlights the safety and efficacy of the transsylvian approach for appropriately selected insular gliomas.
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Michaud K, Duffau H. Surgery of insular and paralimbic diffuse low-grade gliomas: technical considerations. J Neurooncol 2016; 130:289-298. [DOI: 10.1007/s11060-016-2120-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 04/02/2016] [Indexed: 01/16/2023]
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Zhuang DX, Wu JS, Yao CJ, Qiu TM, Lu JF, Zhu FP, Xu G, Zhu W, Zhou LF. Intraoperative Multi-Information-Guided Resection of Dominant-Sided Insular Gliomas in a 3-T Intraoperative Magnetic Resonance Imaging Integrated Neurosurgical Suite. World Neurosurg 2016; 89:84-92. [DOI: 10.1016/j.wneu.2016.01.067] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 01/12/2016] [Accepted: 01/13/2016] [Indexed: 02/08/2023]
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Ekstrand CL, Mickleborough MJS, Fourney DR, Gould LA, Lorentz EJ, Ellchuk T, Borowsky RW. Pre-Surgical Integration of fMRI and DTI of the Sensorimotor System in Transcortical Resection of a High-Grade Insular Astrocytoma. Front Integr Neurosci 2016; 10:15. [PMID: 27013996 PMCID: PMC4786563 DOI: 10.3389/fnint.2016.00015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 02/29/2016] [Indexed: 11/13/2022] Open
Abstract
Herein we report on a patient with a WHO Grade III astrocytoma in the right insular region in close proximity to the internal capsule who underwent a right frontotemporal craniotomy. Total gross resection of insular gliomas remains surgically challenging based on the possibility of damage to the corticospinal tracts. However, maximizing the extent of resection has been shown to decrease future adverse outcomes. Thus, the goal of such surgeries should focus on maximizing extent of resection while minimizing possible adverse outcomes. In this case, pre-surgical planning included integration of functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI), to localize motor and sensory pathways. Novel fMRI tasks were individually developed for the patient to maximize both somatosensory and motor activation simultaneously in areas in close proximity to the tumor. Information obtained was used to optimize resection trajectory and extent, facilitating gross total resection of the astrocytoma. Across all three motor-sensory tasks administered, fMRI revealed an area of interest just superior and lateral to the astrocytoma. Further, DTI analyses showed displacement of the corona radiata around the superior dorsal surface of the astrocytoma, extending in the direction of the activation found using fMRI. Taking into account these results, a transcortical superior temporal gyrus surgical approach was chosen in order to avoid the area of interest identified by fMRI and DTI. Total gross resection was achieved and minor post-surgical motor and sensory deficits were temporary. This case highlights the utility of comprehensive pre-surgical planning, including fMRI and DTI, to maximize surgical outcomes on a case-by-case basis.
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Affiliation(s)
- Chelsea L Ekstrand
- Department of Psychology, University of Saskatchewan Saskatoon, SK, Canada
| | - Marla J S Mickleborough
- Department of Psychology, University of SaskatchewanSaskatoon, SK, Canada; Department of Medical Imaging, Royal University HospitalSaskatoon, SK, Canada
| | - Daryl R Fourney
- Department of Medical Imaging, Royal University HospitalSaskatoon, SK, Canada; Department of Surgery, Division of Neurosurgery, Royal University HospitalSaskatoon, SK, Canada
| | - Layla A Gould
- Department of Psychology, University of Saskatchewan Saskatoon, SK, Canada
| | - Eric J Lorentz
- Department of Psychology, University of Saskatchewan Saskatoon, SK, Canada
| | - Tasha Ellchuk
- Department of Medical Imaging, Royal University Hospital Saskatoon, SK, Canada
| | - Ron W Borowsky
- Department of Psychology, University of SaskatchewanSaskatoon, SK, Canada; Department of Surgery, Division of Neurosurgery, Royal University HospitalSaskatoon, SK, Canada
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Šteňo A, Jezberová M, Hollý V, Timárová G, Šteňo J. Visualization of lenticulostriate arteries during insular low-grade glioma surgeries by navigated 3D ultrasound power Doppler: technical note. J Neurosurg 2016; 125:1016-1023. [PMID: 26848921 DOI: 10.3171/2015.10.jns151907] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Resection of insular gliomas is challenging. In cases of intraoperative injury to the lenticulostriate arteries (LSAs), the usual result is a dense hemiplegia. LSAs are usually localized just behind the medial tumor border but they can also be encased by the tumor. Thus, exact localization of these perforators is important. However, intraoperative localization of LSAs using conventional neuronavigation can be difficult due to brain shift. In this paper, the authors present a novel method of intraoperative LSA visualization by navigated 3D ultrasound (3DUS) power Doppler. This technique enables almost real-time imaging of LSAs and evaluation of their shift during insular tumor resections. METHODS Six patients harboring insular Grade II gliomas were consecutively operated on at the Department of Neurosurgery in Bratislava using visualization of LSAs by navigated 3DUS power Doppler. In all cases, the 3DUS data were repeatedly updated to compensate for the brain shift and display the actual position of LSAs and residual tumor. RESULTS Successful visualization of LSAs was achieved in all cases. During all surgeries, the distance between the bottom of the resection cavity and LSAs could be accurately evaluated; in all tumors the resection approached the LSAs and only a minimal amount of tissue covering these perforators was intentionally left in place to avoid injury to them. CONCLUSIONS Visualization of LSAs by navigated 3DUS power Doppler is a useful tool that may help to prevent injury of LSAs during removal of insular low-grade gliomas. However, reliability of this method has to be carefully evaluated in further studies.
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Affiliation(s)
| | | | - Vladimír Hollý
- Department of Anesthesiology, Slovak Medical University, University Hospital Bratislava, Slovakia
| | - Gabriela Timárová
- II. Department of Neurology, Comenius University, University Hospital Bratislava
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Hervey-Jumper SL, Li J, Osorio JA, Lau D, Molinaro AM, Benet A, Berger MS. Surgical assessment of the insula. Part 2: validation of the Berger-Sanai zone classification system for predicting extent of glioma resection. J Neurosurg 2016; 124:482-8. [DOI: 10.3171/2015.4.jns1521] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Though challenging, maximal safe resection of insular gliomas enhances overall and progression-free survival and deters malignant transformation. Previously published reports have shown that surgery can be performed with low morbidity. The authors previously described a Berger-Sanai zone classification system for insular gliomas. Using a subsequent dataset, they undertook this study to validate this zone classification system for predictability of extent of resection (EOR) in patients with insular gliomas.
METHODS
The study population included adults who had undergone resection of WHO Grade II, III, or IV insular gliomas. In accordance with our prior published report, tumor location was classified according to the Berger-Sanai quadrant-style classification system into Zones I through IV. Interobserver variability was analyzed using a cohort of newly diagnosed insular gliomas and independent classification scores given by 3 neurosurgeons at various career stages. Glioma volumes were analyzed using FLAIR and T1-weighted contrast-enhanced MR images.
RESULTS
One hundred twenty-nine procedures involving 114 consecutive patients were identified. The study population from the authors’ previously published experience included 115 procedures involving 104 patients. Thus, the total experience included 244 procedures involving 218 patients with insular gliomas treated at the authors’ institution. The most common presenting symptoms were seizure (68.2%) and asymptomatic recurrence (17.8%). WHO Grade II glioma histology was the most common (54.3%), followed by Grades III (34.1%) and IV (11.6%). The median tumor volume was 48.5 cm3. The majority of insular gliomas were located in the anterior portion of the insula with 31.0% in Zone I, 10.9% in Zone IV, and 16.3% in Zones I+IV. The Berger-Sanai zone classification system was highly reliable, with a kappa coefficient of 0.857. The median EOR for all zones was 85%. Comparison of EOR between the current and prior series showed no change and Zone I gliomas continue to have the highest median EOR. Short- and long-term neurological complications remain low, and zone classification correlated with short-term complications, which were highest in Zone I and in Giant insular gliomas.
CONCLUSIONS
The previously proposed Berger-Sanai classification system is highly reliable and predictive of insular glioma EOR and morbidity.
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Benet A, Hervey-Jumper SL, Sánchez JJG, Lawton MT, Berger MS. Surgical assessment of the insula. Part 1: surgical anatomy and morphometric analysis of the transsylvian and transcortical approaches to the insula. J Neurosurg 2016; 124:469-81. [DOI: 10.3171/2014.12.jns142182] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Transcortical and transsylvian corridors have been previously described as the main surgical approaches to the insula, but there is insufficient evidence to support one approach versus the other. The authors performed a cadaveric comparative study regarding insular exposure, surgical window and freedom, between the transcortical and transsylvian approaches (with and without cutting superficial sylvian bridging veins). Surgical anatomy and skull surface reference points to the different insular regions are also described.
METHODS
Sixteen cadaveric specimens were embalmed with a customized formula to enhance neurosurgical simulation. Two different blocks were defined in the study: first, transsylvian without (TS) and with the superficial sylvian bridging veins cut (TSVC) and transcortical (TC) approaches to the insula were simulated in all (16) specimens. Insular surface exposure, surgical window and surgical freedom were calculated for each procedure and related to the Berger-Sanai insular glioma classification (Zones I–IV) in 10 specimens. Second, the venous drainage pattern and anatomical landmarks considered critical for surgical planning were studied in all specimens.
RESULTS
In the insular Zone I (anterior-superior), the TC approach provided the best insular exposure compared with both TS and TSVC. The surgical window obtained with the TC approach was also larger than that obtained with the TS. The TC approach provided 137% more surgical freedom than the TS approach. Only the TC corridor provided complete insular exposure. In Zone II (posterior-superior), results depended on the degree of opercular resection. Without resection of the precentral gyrus in the operculum, insula exposure, surgical windows and surgical freedom were equivalent. If the opercular cortex was resected, the insula exposure and surgical freedom obtained through the TC approach was greater to that of the other groups. In Zone III (posterior-inferior), the TC approach provided better surgical exposure than the TS, yet similar to the TSVC. The TC approach provided the best insular exposure, surgical window, and surgical freedom if components of Heschl’s gyrus were resected. In Zone IV (anterior-inferior), the TC corridor provided better exposure than both the TS and the TSVC. The surgical window was equivalent. Surgical freedom provided by the TC was greater than the TS approach. This zone was completely exposed only with the TC approach. A dominant anterior venous drainage was found in 87% of the specimens. In this group, 50% of the specimens had good alternative venous drainage. The sylvian fissure corresponded to the superior segment of the squamosal suture in 14 of 16 specimens. The foramen of Monro was 1.9 cm anterior and 4.42 cm superior to the external acoustic meatus. The M2 branch over the central sulcus of the insula became the precentral M4 (rolandic) artery in all specimens.
CONCLUSIONS
Overall, the TC approach to the insula provided better insula exposure and surgical freedom compared with the TS and the TSVC. Cortical and subcortical mapping is critical during the TC approach to the posterior zones (II and III), as the facial motor and somatosensory functions (Zone II) and language areas (Zone III) may be involved. The evidence provided in this study may help the neurosurgeon when approaching insular gliomas to achieve a greater extent of tumor resection via an optimal exposure.
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Delion M, Mercier P, Brassier G. Arteries and Veins of the Sylvian Fissure and Insula: Microsurgical Anatomy. Adv Tech Stand Neurosurg 2016:185-216. [PMID: 26508410 DOI: 10.1007/978-3-319-21359-0_7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We present a vascular anatomical study of the arteries and veins of the sylvian fissure and insula.A good knowledge of the sylvian fissure, the insula, and their vascular relationship would seem mandatory before performing surgery in this area, whatever the type of surgery (aneurysms, arteriovenous malformations, insular tumors).We start with the sylvian fissure and insula morphology, followed by the MCA description and its perforators, with special attention paid to the insular perforators. We demonstrate that the long insular perforators penetrating in the superior part of the posterior short gyrus and long gyri vascularize, respectively, the corticonuclear and corticospinal fasciculi. We particularly insist too on three anatomical constants regarding the vascularization of the insula, already described in the literature: The superior periinsular sulcus is the only sulcus on the lateral surface of the brain without an artery along its axis; the superior branch of the MCA supplies the anterior insular pole and both the anterior and middle short gyri in 100 % of cases; in at least 90 % of cases, the artery that supplied the central insular sulcus continued on to become the central artery.We end with the anatomical study of the veins and cisterns.
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Affiliation(s)
- Matthieu Delion
- Department of Neurosurgery, Angers Teaching Hospital, Angers, 49933, France.
- Anatomy Laboratory, Medical Faculty, rue haute de Reculée, Angers, 49045, France.
| | - Philippe Mercier
- Department of Neurosurgery, Angers Teaching Hospital, Angers, 49933, France
- Anatomy Laboratory, Medical Faculty, rue haute de Reculée, Angers, 49045, France
| | - Gilles Brassier
- Department of Neurosurgery, Rennes Teaching Hospital, Rennes, 35033, France
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Velasquez C, Caballero H, Vazquez-Barquero A, Vega M, Rial JC, Carcedo-Barrio MC, Martino J. Insular Gliomas with Exophytic Extension to the Sylvian Cistern: A Glioma Growth Pattern That Has Gone Previously Unnoticed. World Neurosurg 2015; 87:200-6. [PMID: 26724624 DOI: 10.1016/j.wneu.2015.12.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 12/03/2015] [Accepted: 12/07/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND An exophytic tumor is defined as a tumor that has its epicenter in the nervous tissue but grows outside the anatomical superficial boundaries of the brain within an adjacent space. Exophytic extension of hemispheric gliomas is extremely rare. The object of this study is to describe the exophytic growth pattern of insular gliomas. METHODS A series of 28 insular gliomas operated on consecutively were analyzed. The definition of exophytic glioma included these 2 criteria: 1) preoperative magnetic resonance imaging with evidence of exophytic local tumor extension outside the anatomical superficial boundaries of the brain; and 2) surgical identification of piamater and arachnoid invasion, with tumor growth to the adjacent cisterns. RESULTS A series of 6 exophytic gliomas (21.4%) are reported, among a series of 28 consecutive insular gliomas operated. The exophytic component originated from the posterior portion of the basal frontal lobe, with extension to the sphenoidal compartment of the sylvian cistern, reaching the temporal pole. All exophytic tumors were type 5A in Yasargil classification. The histologic diagnosis was World Health Organization grade II glioma in 3 cases and anaplastic glioma in 3 cases. All patients underwent surgery, and the exophytic component was removed completely. CONCLUSIONS Radiologic features that define the exophytic growth pattern in insular gliomas are the posterior displacement of the middle cerebral artery and a sharp subarachnoid margin that separates the exophytic tumor from the temporal pole. Contrary to the tumor that infiltrates the anterior perforating substance, the exophytic tumor is amenable for safe and complete resection.
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Affiliation(s)
- Carlos Velasquez
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla (HUMV) and Fundación Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - Hugo Caballero
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla (HUMV) and Fundación Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - Alfonso Vazquez-Barquero
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla (HUMV) and Fundación Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - Marco Vega
- Department of Neurological Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Juan C Rial
- Department of Neurological Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Maria C Carcedo-Barrio
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla (HUMV) and Fundación Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain
| | - Juan Martino
- Department of Neurological Surgery, Hospital Universitario Marqués de Valdecilla (HUMV) and Fundación Instituto de Investigación Marqués de Valdecilla (IDIVAL), Santander, Spain.
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Second Surgery in Insular Low-Grade Gliomas. BIOMED RESEARCH INTERNATIONAL 2015; 2015:497610. [PMID: 26539503 PMCID: PMC4619843 DOI: 10.1155/2015/497610] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 08/15/2015] [Accepted: 08/31/2015] [Indexed: 12/03/2022]
Abstract
Background. Given the technical difficulties, a limited number of works have been published on insular gliomas surgery and risk factors for tumor recurrence (TR) are poorly documented. Objective. The aim of the study was to determine TR in adult patients with initial diagnosis of insular Low-Grade Gliomas (LGGs) that subsequently underwent second surgery. Methods. A consecutive series of 53 patients with insular LGGs was retrospectively reviewed; 23 patients had two operations for TR. Results. At the time of second surgery, almost half of the patients had experienced progression into high-grade gliomas (HGGs). Univariate analysis showed that TR is influenced by the following: extent of resection (EOR) (P < 0.002), ΔVT2T1 value (P < 0.001), histological diagnosis of oligodendroglioma (P = 0.017), and mutation of IDH1 (P = 0.022). The multivariate analysis showed that EOR at first surgery was the independent predictor for TR (P < 0.001). Conclusions. In patients with insular LGG the EOR at first surgery represents the major predictive factor for TR. At time of TR, more than 50% of cases had progressed in HGG, raising the question of the oncological management after the first surgery.
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Martino J, Mato D, de Lucas EM, García-Porrero JA, Gabarrós A, Fernández-Coello A, Vázquez-Barquero A. Subcortical anatomy as an anatomical and functional landmark in insulo-opercular gliomas: implications for surgical approach to the insular region. J Neurosurg 2015; 123:1081-92. [DOI: 10.3171/2014.11.jns141992] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Little attention has been given to the functional challenges of the insular approach to the resection of gliomas, despite the potential damage of essential neural networks that underlie the insula. The object of this study is to analyze the subcortical anatomy of the insular region when infiltrated by gliomas, and compare it with the normal anatomy in nontumoral hemispheres.
METHODS
Ten postmortem human hemispheres were dissected, with isolation of the inferior fronto-occipital fasciculus (IFOF) and the uncinate fasciculus. Probabilistic diffusion tensor imaging (DTI) tractography was used to analyze the subcortical anatomy of the insular region in 10 healthy volunteers and in 22 patients with insular Grade II and Grade III gliomas. The subcortical anatomy of the insular region in these 22 insular gliomas was compared with the normal anatomy in 20 nontumoral hemispheres.
RESULTS
In tumoral hemispheres, the distances between the peri-insular sulci and the lateral surface of the IFOF and uncinate fasciculus were enlarged (p < 0.05). Also in tumoral hemispheres, the IFOF was identified in 10 (90.9%) of 11 patients with an extent of resection less than 80%, and in 4 (36.4%) of 11 patients with an extent of resection equal to or greater than 80% (multivariate analysis: p = 0.03).
CONCLUSIONS
Insular gliomas grow in the space between the lateral surface of the IFOF and uncinate fasciculus and the insular surface, displacing and compressing the tracts medially. Moreover, these tracts may be completely infiltrated by the tumor, with a total disruption of the bundles. In the current study, the identification of the IFOF with DTI tractography was significantly associated with the extent of tumor resection. If the IFOF is not identified preoperatively, there is a high probability of achieving a resection greater than 80%.
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Affiliation(s)
| | - David Mato
- Departments of 1Neurological Surgery and
| | - Enrique Marco de Lucas
- 2Radiology, Hospital Universitario Marqués de Valdecilla and Fundación Instituto de Investigación Marqués de Valdecilla (IDIVAL)
| | | | - Andreu Gabarrós
- 4Department of Neurological Surgery, Hospital Universitari de Bellvitge, Barcelona, Spain
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Maesawa S, Fujii M, Futamura M, Hayashi Y, Iijima K, Wakabayashi T. A case of secondary somatosensory epilepsy with a left deep parietal opercular lesion: successful tumor resection using a transsubcentral gyral approach during awake surgery. J Neurosurg 2015; 124:791-8. [PMID: 26295917 DOI: 10.3171/2015.2.jns142737] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Few studies have examined the clinical characteristics of patients with lesions in the deep parietal operculum facing the sylvian fissure, the region recognized as the secondary somatosensory area (SII). Moreover, surgical approaches in this region are challenging. In this paper the authors report on a patient presenting with SII epilepsy with a tumor in the left deep parietal operculum. The patient was a 24-year-old man who suffered daily partial seizures with extremely uncomfortable dysesthesia and/or occasional pain on his right side. MRI revealed a tumor in the medial aspect of the anterior transverse parietal gyrus, surrounding the posterior insular point. Long-term video electroencephalography monitoring with scalp electrodes failed to show relevant changes to seizures. Resection with cortical and subcortical mapping under awake conditions was performed. A negative response to stimulation was observed at the subcentral gyrus during language and somatosensory tasks; thus, the transcortical approach (specifically, a transsubcentral gyral approach) was used through this region. Subcortical stimulation at the medial aspect of the anterior parietal gyrus and the posterior insula around the posterior insular point elicited strong dysesthesia and pain in his right side, similar to manifestation of his seizure. The tumor was completely removed and pathologically diagnosed as pleomorphic xanthoastrocytoma. His epilepsy disappeared without neurological deterioration postoperatively. In this case study, 3 points are clinically significant. First, the clinical manifestation of this case was quite rare, although still representative of SII epilepsy. Second, the location of the lesion made surgical removal challenging, and the transsubcentral gyral approach was useful when intraoperative mapping was performed during awake surgery. Third, intraoperative mapping demonstrated that the patient experienced pain with electrical stimulation around the posterior insular point. Thus, this report demonstrated the safe and effective use of the transsubcentral gyral approach during awake surgery to resect deep parietal opercular lesions, clarified electrophysiological characteristics in the SII area, and achieved successful tumor resection with good control of epilepsy.
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Affiliation(s)
- Satoshi Maesawa
- Department of Neurosurgery, Nagoya University Graduate School of Medicine;,Brain and Mind Research Center, Nagoya University
| | - Masazumi Fujii
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
| | - Miyako Futamura
- Department of Rehabilitation, National Hospital Organization, Nagoya Medical Center; and
| | - Yuichiro Hayashi
- Information and Communications Headquarters, Nagoya University, Nagoya, Japan
| | - Kentaro Iijima
- Department of Neurosurgery, Nagoya University Graduate School of Medicine
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Pitskhelauri DI, Bykanov AE, Zhukov VY, Kachkov IA, Buklina SB, Tonoyan AS. [Review of surgical treatment of insular gliomas: challenges and opportunities]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2015; 79:111-116. [PMID: 26182444 DOI: 10.17116/neiro2015792111-116] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Intracerebral tumors of the insular lobe are quite frequent, however treatment of patients with this pathology still remains a challenging and controversial issue of neurosurgery. First of all, this is associated with the localization of tumors in the area of eloquent anatomical structures: M1--M2 segment of the middle cerebral artery, lenticulostriate arteries, basal ganglia, and internal capsule, which causes a high rate of postoperative complications in these patients. Most insular tumors are amenable for resection with a reasonable rate of postoperative complications, although most of the surgery-related complications resulting in substantial deficits are due to lesions of eloquent anatomical structures located in this compact anatomical space. Therefore, the aim of this work was to analyze the literature regarding the issues of clinical presentation, diagnosis, and aspects of surgical treatment of insular tumors.
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Affiliation(s)
| | - A E Bykanov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - V Yu Zhukov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I A Kachkov
- M.F. Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia
| | - S B Buklina
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A S Tonoyan
- Burdenko Neurosurgical Institute, Moscow, Russia
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Finet P, Nguyen DK, Bouthillier A. Vascular consequences of operculoinsular corticectomy for refractory epilepsy. J Neurosurg 2015; 122:1293-8. [DOI: 10.3171/2014.10.jns141246] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Surgery in the insular region is considered challenging because of its vascular relationships, the proximity of functional structures, and its deep location in the sylvian fissure. The authors report the incidence and consequences of ischemic lesions after operculoinsular corticectomy for refractory epilepsy.
METHODS
The authors retrospectively reviewed the data of all patients who underwent an insular resection with or without an opercular resection for refractory epilepsy at their center. All patients underwent postoperative MRI, enabling a radiological analysis of the ischemic lesions as a result of the corticectomies. The resections were classified according to the location and extent of the insular corticectomy and the type of operculectomy. Each patient underwent clinical follow-up.
RESULTS
Twenty patients underwent surgery. All patients underwent insular corticectomy with or without an operculectomy. Ischemic lesions were identified in 12 patients (60%). In these patients, 11 ischemic lesions (55%) were related to the insular corticectomy, and 1 was related to the associated periinsular resection. The ischemic lesions associated with the insulectomies were typically located in the corona radiata running from the insula to the periventricular region. Nine patients (45%) developed a postoperative neurological deficit, among whom 6 (67%) had an insular corticectomy–related ischemic lesion. All reported neurological deficits were transient. Five patients (25%) had ischemic lesions without neurological deficit.
CONCLUSIONS
Operculoinsular corticectomies are associated with ischemic lesions in approximately 60% of patients. However, given that no patient had a definitive postoperative deficit, these ischemic lesions have few clinical consequences. Therefore, this surgical procedure can be considered reasonably safe for the treatment of refractory epilepsy.
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Affiliation(s)
| | - Dang Khoa Nguyen
- 2Neurology, University of Montreal Medical Center (CHUM), Montreal, Quebec, Canada
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Harteveld AA, De Cocker LJL, Dieleman N, van der Kolk AG, Zwanenburg JJM, Robe PA, Luijten PR, Hendrikse J. High-resolution postcontrast time-of-flight MR angiography of intracranial perforators at 7.0 Tesla. PLoS One 2015; 10:e0121051. [PMID: 25774881 PMCID: PMC4361559 DOI: 10.1371/journal.pone.0121051] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 02/06/2015] [Indexed: 11/24/2022] Open
Abstract
Background and Purpose Different studies already demonstrated the benefits of 7T for precontrast TOF-MRA in the visualization of intracranial small vessels. The aim of this study was to assess the performance of high-resolution 7T TOF-MRA after the administration of a gadolinium-based contrast agent in visualizing intracranial perforating arteries. Materials and Methods Ten consecutive patients (7 male; mean age, 50.4 ± 9.9 years) who received TOF-MRA at 7T after contrast administration were retrospectively included in this study. Intracranial perforating arteries, branching from the parent arteries of the circle of Willis, were identified on all TOF-MRA images. Provided a TOF-MRA before contrast administration was present, a direct comparison between pre- and postcontrast TOF-MRA was made. Results It was possible to visualize intracranial perforating arteries branching off from the entire circle of Willis, and their proximal branches. The posterior cerebral artery (P1 and proximal segment of P2) appeared to have the largest number of visible perforating branches (mean of 5.1 in each patient, with a range of 2–7). The basilar artery and middle cerebral artery (M1 and proximal segment M2) followed with a mean number of 5.0 and 3.5 visible perforating branches (range of 1–9 and 1–8, respectively). Venous contamination in the postcontrast scans sometimes made it difficult to discern the arterial or venous nature of a vessel. Conclusion High-resolution postcontrast TOF-MRA at 7T was able to visualize multiple intracranial perforators branching off from various parts of the circle of Willis and proximal intracranial arteries. Although confirmation in a larger study is needed, the administration of a contrast agent for high-resolution TOF-MRA at 7T seems to enable a better visualization of the distal segment of certain intracranial perforators.
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Affiliation(s)
- Anita A. Harteveld
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
- * E-mail:
| | | | - Nikki Dieleman
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anja G. van der Kolk
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jaco J. M. Zwanenburg
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pierre A. Robe
- Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter R. Luijten
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
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Rey-Dios R, Cohen-Gadol AA. Technical nuances for surgery of insular gliomas: lessons learned. Neurosurg Focus 2015; 34:E6. [PMID: 23373451 DOI: 10.3171/2012.12.focus12342] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Insular gliomas were traditionally considered a nonsurgical entity due to the high morbidity associated with resection. For the past 20 years, advances in microsurgical and brain mapping techniques have allowed neurosurgeons to resect insular gliomas with acceptable morbidity rates. Maximizing the extent of resection is nowadays the goal of surgery since this has proven to be an independent factor contributing to longer survival. Despite much progress, insular tumors remain a challenge for the neurosurgeon due to the complex anatomy of the region and technical expertise required to minimize morbidity during surgery. Herein, the authors describe the current surgical nuances, based on their experience and a literature review, that will allow the surgeon to achieve a thorough resection while ensuring patient safety. The key factors for successful surgery in the insular region include detailed knowledge of the surgical anatomy, mastery of the nuances of cortical and subcortical mapping methods, and meticulous microsurgical technique.
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Affiliation(s)
- Roberto Rey-Dios
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Boucher O, Rouleau I, Escudier F, Malenfant A, Denault C, Charbonneau S, Finet P, Lassonde M, Lepore F, Bouthillier A, Nguyen DK. Neuropsychological performance before and after partial or complete insulectomy in patients with epilepsy. Epilepsy Behav 2015; 43:53-60. [PMID: 25561378 DOI: 10.1016/j.yebeh.2014.11.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 11/11/2014] [Accepted: 11/15/2014] [Indexed: 10/24/2022]
Abstract
Resection of the insular cortex is becoming more frequent as it is increasingly recognized that a nonnegligible proportion of surgical candidates with drug-resistant epilepsy have an epileptogenic zone that involves the insula. In the last decades, however, the insula has been proposed to be involved in several neuropsychological functions, and there is a lack of documentation on whether partial or complete insulectomy results in permanent cognitive impairments in this clinical population. In this study, we conducted standard preoperative and postoperative neuropsychological assessments in 18 patients undergoing epilepsy surgery that included the removal of the insula in the right (n=13) or the left (n=5) hemisphere. Postoperative testing was conducted at least five months after surgery. Cognitive impairments were common and heterogeneous prior to surgery, with language and verbal memory impairments being especially frequent among patients in whom epileptic seizures originated from the left hemisphere. After surgery, declines and improvements occurred on a variety of outcomes, although new deficits were relatively infrequent among patients who had obtained normal performance at baseline. Statistical comparisons between preoperative and postoperative assessments revealed significant deterioration of only one outcome - the color naming condition of the Stroop test - which relies on oro-motor speed and lexical access. These findings suggest that partial or complete resection of the insular cortex in patients with drug-refractory epilepsy can be conducted without major permanent neuropsychological impairments in a vast majority of patients. However, small decrements in specific cognitive functions can be expected, which should also be taken into account when considering the surgical option in this clinical population.
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Affiliation(s)
- Olivier Boucher
- Département de psychologie, Université de Montréal, Montréal, QC, Canada
| | - Isabelle Rouleau
- Centre hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montréal, QC, Canada; Département de psychologie, Université du Québec à Montréal, Montréal, QC, Canada
| | - Frédérique Escudier
- Département de psychologie, Université du Québec à Montréal, Montréal, QC, Canada
| | - Annie Malenfant
- Centre hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montréal, QC, Canada
| | - Carole Denault
- Centre hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montréal, QC, Canada
| | - Simon Charbonneau
- Centre hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montréal, QC, Canada
| | - Patrice Finet
- Centre hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montréal, QC, Canada
| | - Maryse Lassonde
- Département de psychologie, Université de Montréal, Montréal, QC, Canada
| | - Franco Lepore
- Département de psychologie, Université de Montréal, Montréal, QC, Canada
| | - Alain Bouthillier
- Centre hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montréal, QC, Canada
| | - Dang K Nguyen
- Centre hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montréal, QC, Canada.
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Bykanov AE, Pitskhelauri DI, Dobrovol'skiy GF, Shkarubo MA. Surgical anatomy of the insular cortex. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2015; 79:48-60. [PMID: 26529622 DOI: 10.17116/neiro201579448-60] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE The objective of the study was to investigate the surgical anatomy of the insular cortex, morphology and vascularization of the insula and adjacent opercula in terms of transsylvian and transcortical approaches, and identification of the permissible anatomical boundaries for resection of glial tumors of the insula. MATERIAL AND METHODS The study was conducted on 18 anatomical specimens fixed in an alcohol-glycerol solution. Perfusion of the internal carotid artery with red latex was used to study the arterial system. Dissection of the arteries and Sylvian fissure, investigation of the morphological features of the opercula as well as simulation of the transsylvian and transcortical approaches to the insula were performed using a surgical microscope, in a certain sequence. RESULTS In the trassylvian approach, the anteroinferior part of the insula (including the limen insulae) is the most technically easy-to-reach area, whereas the superior parts of the insula are the most difficult-to-reach areas. With the tumor localized in the superior insula, the transcortical approach may be recommended that, unlike the transsylvian approach, does not require a significant retraction of the brain matter and provides a larger surgical corridor. The transcortical approach, regardless the insular region, provides a better surgical view and workspace compared to the transsylvian approach. However, the previous approach is characterized by less access to the important anatomical landmarks such as the peri-insular sulci, limen insulae, and lateral lenticulostriate arteries. Furthermore, the approach requires dissection of the brain matter of the frontal and temporal lobes. CONCLUSION Detailed knowledge of the surgical anatomy of the insular region provides correct intraoperative identification of a number of the major anatomical landmarks (limen insulae, peri-insular sulci, most distal lenticulostriate artery) and facilitates choosing the proper surgical approach.
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Affiliation(s)
- A E Bykanov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | - M A Shkarubo
- Burdenko Neurosurgical Institute, Moscow, Russia
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Bykanov AE, Pitskhelauri DI, Pronin IN, Tonoyan AS, Kornienko VN, Zakharova NE, Turkin AM, Sanikidze AZ, Shkarubo MA, Shkatova AM, Shults EI. 3D-TOF MR-angiography with high spatial resolution for surgical planning in insular lobe gliomas. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2015; 79:5-14. [PMID: 26529529 DOI: 10.17116/neiro20157935-14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
UNLABELLED Despite the obvious progress in modern neurosurgery, surgery for glial tumors of the insular lobe is often associated with a high risk of postoperative neurological deficit, which is primarily caused by damage to perforating arteries of the M1 segment of the middle cerebral artery. OBJECTIVE The work is aimed at evaluating the effectiveness of high resolution time-of-flight (3D-TOF) MR angiography in imaging of medial and lateral lenticulostriate arteries and determining their relationship to tumor edge in patients with gliomas of the insula. MATERIAL AND METHODS 3D-TOF MR angiography data were analyzed in 20 patients with primarily diagnosed cerebral gliomas involving the insula. All patients underwent non-contrast enhanced 3D-TOF MR angiography. In 6 cases, 3D-TOF MRA was performed before and after contrast enhancement. RESULTS 3D-TOF angiography before intravenous contrast injection was capable of visualizing the medial lenticulostriate arteries in 19 patients (95% of all cases) and lateral lenticulostriate arteries in 18 patients (90% of all cases). Contrast-enhanced 3D-TOF angiography allows for better visualization of both the proximal and distal segments of lenticulostriate arteries. Three variants of relationship between the tumor and lenticulostriate arteries were identified. Variant I: the tumor grew over the arteries without their displacement in 2 cases (10% of the total number of observations); variant II: the tumor caused medial displacement of arteries without growing over them in 11 cases (55% of the total number of observations); variant III: the tumor partially grew over and displaced arteries in 2 cases (10%). In 25% of cases (5 patients), tumor was poorly visualized on 3D-TOF MR angiograms because their signal characteristics did not differ from those of the medulla (tumor tissue was T1 isointense). As a result, it was impossible to determine the relationship between the tumor and lenticulostriate arteries. CONCLUSION High spatial resolution time-of-flight MR angiography can be recommended for preoperative imaging of lenticulostriate arteries to plan the extent of neurosurgical resection in patients with glial tumors of the insular lobe.
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Affiliation(s)
- A E Bykanov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - I N Pronin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A S Tonoyan
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | - A M Turkin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - M A Shkarubo
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A M Shkatova
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - E I Shults
- Burdenko Neurosurgical Institute, Moscow, Russia
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Bucheli C, Mato D, Marco de Lucas E, García-Porrero JA, Vázquez-Barquero A, Martino J. Fascículos asociativos ínsulo-operculares: revisión de su anatomía y de las implicaciones para el abordaje transopercular a la ínsula. Neurocirugia (Astur) 2014; 25:268-74. [DOI: 10.1016/j.neucir.2014.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 07/05/2014] [Accepted: 07/08/2014] [Indexed: 12/27/2022]
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Delion M, Mercier P. Microanatomical study of the insular perforating arteries. Acta Neurochir (Wien) 2014; 156:1991-7; discussion 1997-8. [PMID: 24986536 DOI: 10.1007/s00701-014-2167-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 06/19/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND The insular perforating arteries originate from the middle cerebral artery. They have only been very partially described up to now. In the literature, they come from the M2 segment and three types are listed: the short, medium and long perforators. The first two types supply the claustrum as well as the external and extreme capsules. OBJECTIVE We describe the anatomy of long perforating insular arteries and their arterial contribution to the main white matter bundles of the oval center of Vieussens. MATERIALS AND METHOD Twenty adult cadaveric hemispheres were studied after perfusion of the arteries and veins with colored latex. The arteries were dissected and photographed under an operating microscope. RESULTS The long insular perforating arteries come from the M2 segment or from the junction of the M2 and M3 segments and sometimes from the M3 segment. They often perforate the insular cortex on the top of the posterior short insular gyrus and the insular long gyri, or in the superior peri-insular sulcus, before coming together in the oval center. At this level, they give arterial contribution to the main white matter bundles such as corticospinal and corticonuclear tracts for motricity, and the arcuate fasciculus and the occipitofrontal tract for language in the dominant hemisphere. CONCLUSION These perforating arteries have to be carefully respected during insular surgery to avoid neurologic weakness.
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Affiliation(s)
- Matthieu Delion
- Department of Neurosurgery, Angers Teaching Hospital, 49933, Angers, France,
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83
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Duffau H. Intraoperative cortico–subcortical stimulations in surgery of low-grade gliomas. Expert Rev Neurother 2014; 5:473-85. [PMID: 16026231 DOI: 10.1586/14737175.5.4.473] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In order to increase the impact of surgery on the natural history of low-grade glioma, resection should be of maximum importance. Nevertheless, since low-grade gliomas are frequently located in eloquent structures, function needs to be preserved. Therefore, studying the functional organization of the brain is mandatory for each patient due to the inter-individual anatomofunctional variability, increased in tumors due to cerebral plasticity. This strategy enables performance of a resection according to functional boundaries. However, preoperative neurofunctional imaging only allows the study of the gray matter. Consequently, since low-grade glioma invades cortical and subcortical structures and shows an infiltrative progression along the fibers, the goal of this review is to focus on the techniques able to map both cortical and subcortical regions. In addition to diffusion tensor imaging, which gives only anatomical information and still needs to be validated, intraoperative direct cortico-subcortical electrostimulation is the sole current method allowing a reliable study of the individual anatomofunctional connectivity, concerning sensorimotor, language and other cognitive functions. Its actual contribution is detailed, both in clinical issues, especially the improvement of the benefit/risk ratio of low-grade glioma resection, and in fundamental applications--namely, a new door to the connectionism and cerebral plasticity.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, INSERM U678, UPMC, Hôpital Salpêtrière, 47-83 Bd de l'hôpital, 75013, Paris, France.
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85
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Ius T, Pauletto G, Isola M, Gregoraci G, Budai R, Lettieri C, Eleopra R, Fadiga L, Skrap M. Surgery for insular low-grade glioma: predictors of postoperative seizure outcome. J Neurosurg 2013; 120:12-23. [PMID: 24236654 DOI: 10.3171/2013.9.jns13728] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Although a number of recent studies on the surgical treatment of insular low-grade glioma (LGG) have demonstrated that aggressive resection leads to increased overall patient survival and decreased malignant progression, less attention has been given to the results with respect to tumor-related epilepsy. The aim of this investigation was to evaluate the impact of volumetric, histological, and intraoperative neurophysiological factors on seizure outcome in patients with insular LGG. METHODS The authors evaluated predictors of seizure outcome with special emphasis on both the extent of tumor resection (EOR) and the tumor's infiltrative pattern quantified by computing the difference between the preoperative T2- and T1-weighted MR images (ΔVT2T1) in 52 patients with preoperative drug-resistant epilepsy. RESULTS The 12-month postoperative seizure outcome (Engel class) was as follows: seizure free (Class I), 67.31%; rare seizures (Class II), 7.69%; meaningful seizure improvement (Class III), 15.38%; and no improvement or worsening (Class IV), 9.62%. Poor seizure control was more common in patients with a longer preoperative seizure history (p < 0.002) and higher frequency of seizures (p = 0.008). Better seizure control was achieved in cases with EOR ≥ 90% (p < 0.001) and ΔVT2T1 < 30 cm(3) (p < 0.001). In the final model, ΔVT2T1 proved to be the strongest independent predictor of seizure outcome in insular LGG patients (p < 0.0001). CONCLUSIONS No or little postoperative seizure improvement occurs mainly in cases with a prevalent infiltrative tumor growth pattern, expressed by high ΔVT2T1 values, which consequently reflects a smaller EOR.
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86
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Tamura A, Kasai T, Akazawa K, Nagakane Y, Yoshida T, Fujiwara Y, Kuriyama N, Yamada K, Mizuno T, Nakagawa M. Long insular artery infarction: characteristics of a previously unrecognized entity. AJNR Am J Neuroradiol 2013; 35:466-71. [PMID: 23969339 DOI: 10.3174/ajnr.a3704] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE The infarctions arising in the long insular arteries of the M2 segment have been poorly described in the past. The purpose of this study was to investigate the incidence, clinical characteristics, and pathogenesis of long insular artery infarcts. MATERIALS AND METHODS Patients with acute isolated infarcts in territories of the long insular arteries and lenticulostriate arteries were retrospectively reviewed. The long insular artery territory was defined as the area above the lenticulostriate artery territory at the level of centrum semiovale. On the coronal section, it lies between the tip of the anterior horn and the top of the superior limb of the insular cleft. Clinical features and prevalence of embolic sources were compared between the 2 groups. RESULTS Of 356 consecutive patients with acute ischemic stroke, 8 (2.2%) had a long insular artery infarct (long insular artery group) and 50 (14.0%) had a lenticulostriate artery infarct (lenticulostriate artery group). There were no differences in age, sex, prevalence of risk factors, neurologic deficit, or incidence of lacunar syndromes between these groups. Abrupt onset was more common in the long insular artery than in the lenticulostriate artery group (P = .004). The prevalence of embolic high-risk sources (eg, atrial fibrillation) was not significantly different between these groups, but the combined prevalence of all embolic sources, including moderate-risk sources, was significantly higher in the long insular artery group (P = .048). CONCLUSIONS Isolated infarction caused by long insular artery occlusion is not rare. Abrupt onset is more common for long insular artery infarction, and this finding could be attributed to the higher incidence of an embolic etiology as the pathogenesis of infarction.
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Affiliation(s)
- A Tamura
- From the Departments of Neurology (A.T., T.K., Y.N., T.Y., Y.F., N.K., T.M., M.N.)
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Blauwblomme T, David O, Minotti L, Job AS, Chassagnon S, Hoffman D, Chabardes S, Kahane P. Prognostic value of insular lobe involvement in temporal lobe epilepsy: A stereoelectroencephalographic study. Epilepsia 2013; 54:1658-67. [DOI: 10.1111/epi.12260] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Thomas Blauwblomme
- Department of Pediatric Neurosurgery; APHP; Hospital Necker; Paris France
- University “Paris Descartes”; Sorbonne Paris Cité; Paris France
- INSERM U836; Institute for Neuroscience; Grenoble France
| | - Olivier David
- INSERM U836; Institute for Neuroscience; Grenoble France
- University Joseph Fourrier; Grenoble France
| | - Lorella Minotti
- INSERM U836; Institute for Neuroscience; Grenoble France
- University Joseph Fourrier; Grenoble France
- Department of Neurology; University Hospital; Grenoble France
| | - Anne-Sophie Job
- INSERM U836; Institute for Neuroscience; Grenoble France
- University Joseph Fourrier; Grenoble France
- Department of Neurology; University Hospital; Grenoble France
| | | | | | - Stéphan Chabardes
- INSERM U836; Institute for Neuroscience; Grenoble France
- University Joseph Fourrier; Grenoble France
- Department of Neurosurgery; University Hospital; Grenoble France
| | - Philippe Kahane
- INSERM U836; Institute for Neuroscience; Grenoble France
- University Joseph Fourrier; Grenoble France
- Department of Neurology; University Hospital; Grenoble France
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88
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Kaneko N, Boling WW, Shonai T, Ohmori K, Shiokawa Y, Kurita H, Fukushima T. Delineation of the safe zone in surgery of sylvian insular triangle: morphometric analysis and magnetic resonance imaging study. Neurosurgery 2013; 70:290-8; discussion 298-9. [PMID: 21841521 DOI: 10.1227/neu.0b013e3182315112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Surgery within the insula carries significant risk of morbidity, particularly hemiparesis, because of the difficulty in detecting the internal capsule boundaries. OBJECTIVE We analyzed the anatomy of the insula and identified landmarks anticipated to facilitate surgery for intrinsic insular lesions. METHODS Insular region anatomy was studied in 11 cadaveric brains harvested within 72 hours postmortem. MRI of the specimens was acquired using 3.0 T with T2-weighting and 25 directions of diffusion tensor imaging. Landmarks easily recognizable during surgery were identified on the surface of the insula. The interrelationships between surface landmarks and critical structures were analyzed. RESULTS The posterior inferior insular point (PIIP) and the upper central insular point (UCIP) were newly established as landmarks on the insula. The PIIP corresponded to the obvious bend in the posterior long insular gyrus. The UCIP is the meeting point between the central insular sulcus and superior peri-insular sulcus. The corticospinal tract was identified as a high-intensity area in the posterior limb of the internal capsule on T2-weighted imaging and its course confirmed with diffusion tensor imaging tractography. The corticospinal tract took a course deep to the posterosuperior insula on T2-weighted imaging, 4.8 mm from the UCIP and 6.2 mm from the PIIP. CONCLUSION The posterosuperior part of the insula forms the region at greatest risk to corticospinal tract injury. The PIIP and UCIP are crucial to understanding the relationship of the insula with the posterior limb of the internal capsule including the corticospinal tract.
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Affiliation(s)
- Nobuyuki Kaneko
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, USA.
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Garrett MC, Pouratian N, Liau LM. Use of language mapping to aid in resection of gliomas in eloquent brain regions. Neurosurg Clin N Am 2012; 23:497-506. [PMID: 22748661 DOI: 10.1016/j.nec.2012.05.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Studies looking at resection in high-grade gliomas have had mixed results. The authors briefly review the literature regarding the value of the extent of resection. They proceed to the preoperative and intraoperative tools available to the neurosurgeon to distinguish eloquent from noneloquent language cortex and fibers, including the emerging roles of functional magnetic resonance imaging diffusion tensor imaging tractography and direct cortical/subcortical stimulation in the surgical management of tumors in eloquent areas. Finally, the authors evaluate the postoperative course of these patients and the effect of language deficits on their quality of life.
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Affiliation(s)
- Matthew C Garrett
- UCLA Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90096-6901, USA
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90
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Ius T, Isola M, Budai R, Pauletto G, Tomasino B, Fadiga L, Skrap M. Low-grade glioma surgery in eloquent areas: volumetric analysis of extent of resection and its impact on overall survival. A single-institution experience in 190 patients. J Neurosurg 2012; 117:1039-52. [PMID: 23039150 DOI: 10.3171/2012.8.jns12393] [Citation(s) in RCA: 196] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Object
A growing number of published studies have recently demonstrated the role of resection in overall survival (OS) for patients with gliomas. In this retrospective study, the authors objectively investigated the role of the extent of resection (EOR) in OS in patients with low-grade gliomas (LGGs).
Methods
Between 1998 and 2011, 190 patients underwent surgery for LGGs. All surgical procedures were conducted under corticosubcortical stimulation. The EOR was established by analyzing the pre- and postoperative volumes of the gliomas on T2-weighted MRI studies. The difference between the preoperative tumor volumes was also investigated by measuring the volumetric difference between the T2- and T1-weighted MRI images (ΔVT2T1) to evaluate how the diffusive tumor-growing pattern affected the EOR achieved.
Results
The median preoperative tumor volume was 55 cm3, and in almost half of the patients the EOR was greater than 90%. In this study, patients with an EOR of 90% or greater had an estimated 5-year OS rate of 93%, those with EOR between 70% and 89% had a 5-year OS rate of 84%, and those with EOR less than 70% had a 5-year OS rate of 41% (p < 0.001). New postoperative deficits were noted in 43.7% of cases, while permanent deficits occurred in 3.16% of cases. There were 41 deaths (21.6%), and the median follow-up was 4.7 years.
A further volumetric analysis was also conducted to compare 2 different intraoperative protocols (Series 1 [intraoperative electrical stimulation alone] vs Series 2 [intraoperative stimulation plus overlap of functional MRI/fiber tracking diffusion tensor imaging data on a neuronavigation system]). Patients in Series 1 had a median EOR of 77%, while those in Series 2 had a median EOR of 90% (p = 0.0001). Multivariate analysis showed that OS is influenced not only by EOR (p = 0.001) but also by age (p = 0.003), histological subtype (p = 0.005), and the ΔVT2T1 value (p < 0.0001). Progression-free survival is similarly influenced by histological subtype (fibrillary astrocytoma, p = 0.003), EOR (p < 0.0001), and ΔVT2T1 value (p < 0.0001), as is malignant progression–free survival (p = 0.003, p < 0.0001, and p < 0.0001, respectively). Finally, the study shows that the higher the ΔVT2T1 value, the less extensive the currently possible resection, highlighting an apparent correlation between the ΔVT2T1 value itself and EOR (p < 0.0001).
Conclusions
The EOR and the ΔVT2T1 values are the strongest independent predictors in improving OS as well as in delaying tumor progression and malignant transformation. Furthermore, the ΔVT2T1 value may be useful as a predictive index for EOR. Finally, due to intraoperative corticosubcortical mapping and the overlap of functional data on the neuronavigation system, major resection is possible with an acceptable risk and a significant increase in expected OS.
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Affiliation(s)
- Tamara Ius
- 1Departments of Neurosurgery and
- 2Department of Robotics, Brain and Cognitive Sciences, Instituto Italiano di Tecnologia, Genoa; and
| | - Miriam Isola
- 3Department of Medical and Biological Sciences, Section of Statistics, University of Udine
| | - Riccardo Budai
- 4Neurology, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine
| | - Giada Pauletto
- 4Neurology, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine
| | - Barbara Tomasino
- 5IRCCS “E. Medea,” Polo Regionale del FVG, San Vito al Tagliamento, Pordenone; and
| | - Luciano Fadiga
- 2Department of Robotics, Brain and Cognitive Sciences, Instituto Italiano di Tecnologia, Genoa; and
- 6Section of Human Physiology, University of Ferrara, Italy
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Chacko AG, Thomas SG, Babu KS, Daniel RT, Chacko G, Prabhu K, Cherian V, Korula G. Awake craniotomy and electrophysiological mapping for eloquent area tumours. Clin Neurol Neurosurg 2012. [PMID: 23177182 DOI: 10.1016/j.clineuro.2012.10.022] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE An awake craniotomy facilitates radical excision of eloquent area gliomas and ensures neural integrity during the excision. The study describes our experience with 67 consecutive awake craniotomies for the excision of such tumours. METHODS Sixty-seven patients with gliomas in or adjacent to eloquent areas were included in this study. The patient was awake during the procedure and intraoperative cortical and white matter stimulation was performed to safely maximize the extent of surgical resection. RESULTS Of the 883 patients who underwent craniotomies for supratentorial intraaxial tumours during the study period, 84 were chosen for an awake craniotomy. Sixty-seven with a histological diagnosis of glioma were included in this study. There were 55 men and 12 women with a median age of 34.6 years. Forty-two (62.6%) patients had positive localization on cortical stimulation. In 6 (8.9%) patients white matter stimulation was positive, five of whom had responses at the end of a radical excision. In 3 patients who developed a neurological deficit during tumour removal, white matter stimulation was negative and cessation of the surgery did not result in neurological improvement. Sixteen patients (24.6%) had intraoperative neurological deficits at the time of wound closure, 9 (13.4%) of whom had persistent mild neurological deficits at discharge, while the remaining 7 improved to normal. At a mean follow-up of 40.8 months, only 4 (5.9%) of these 9 patients had persistent neurological deficits. CONCLUSION Awake craniotomy for excision of eloquent area gliomas enable accurate mapping of motor and language areas as well as continuous neurological monitoring during tumour removal. Furthermore, positive responses on white matter stimulation indicate close proximity of eloquent cortex and projection fibres. This should alert the surgeon to the possibility of postoperative deficits to change the surgical strategy. Thus the surgeon can resect tumour safely, with the knowledge that he has not damaged neurological function up to that point in time thus maximizing the tumour resection and minimizing neurological deficits.
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Affiliation(s)
- Ari George Chacko
- Department of Neurological Sciences, Section of Neurosurgery, Christian Medical College, Vellore, Tamil Nadu, India
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Potts MB, Chang EF, Young WL, Lawton MT. Transsylvian-transinsular approaches to the insula and basal ganglia: operative techniques and results with vascular lesions. Neurosurgery 2012; 70:824-34; discussion 834. [PMID: 21937930 DOI: 10.1227/neu.0b013e318236760d] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Lesions in the insula and basal ganglia can be risky to resect because of their depth and proximity to critical structures, particularly in the dominant hemisphere. Transsylvian approaches shorten the surgical distance to these lesions, preserve perisylvian temporal and frontal cortex, and minimize brain transgression. OBJECTIVE To report our experience with transsylvian-transinsular approaches to vascular lesions. METHODS The anterior approach opened the sphenoidal and insular portions of the sylvian fissure and exposed the limen insulae and short gyri, whereas the posterior approach opened the insular and opercular portions of the sylvian fissure and exposed the circular sulcus and long gyri. RESULTS Forty-one patients with vascular lesions (24 arteriovenous malformations [AVMs] and 17 cavernous malformations) were treated surgically with a transsylvian-transinsular approach. Complete resection was obtained in 87.5% of AVMs and 95% of cavernous malformations. Permanent neurological morbidity related to surgery was observed in 2 AVM patients (5%), with the remaining 39 patients (95%) improved or unchanged postoperatively (modified Rankin Scale scores 0-2 in 83%). There were no new language deficits in patients with dominant hemisphere lesions. CONCLUSION Transsylvian-transinsular approaches safely expose vascular pathology in or deep to the insula while preserving overlying eloquent cortex in the frontal and temporal lobes. The anterior transsylvian-transinsular approach can be differentiated from the posterior approach based on technical differences in splitting the sylvian fissure and anatomic differences in final exposure. Discriminating patient selection and careful microsurgical technique are essential.
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Affiliation(s)
- Matthew B Potts
- Department of Neurological Surgery, University of California, San Francisco, California 94143-0112, USA
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Skrap M, Mondani M, Tomasino B, Weis L, Budai R, Pauletto G, Eleopra R, Fadiga L, Ius T. Surgery of insular nonenhancing gliomas: volumetric analysis of tumoral resection, clinical outcome, and survival in a consecutive series of 66 cases. Neurosurgery 2012; 70:1081-93; discussion 1093-4. [PMID: 22067417 DOI: 10.1227/neu.0b013e31823f5be5] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite intraoperative technical improvements, the insula remains a challenging area for surgery because of its critical relationships with vascular and neurophysiological functional structures. OBJECTIVE To retrospectively investigate the morbidity profile in insular nonenhancing gliomas, with special emphasis on volumetric analysis of tumoral resection. METHODS From 2000 to 2010, 66 patients underwent surgery. All surgical procedures were conducted under cortical-subcortical stimulation and neurophysiological monitoring. Volumetric scan analysis was applied on T2-weighted magnetic resonance images (MRIs) to establish preoperative and postoperative tumoral volume. RESULTS The median preoperative tumor volume was 108 cm. The median extent of resection was 80%. The median follow-up was 4.3 years. An immediate postoperative worsening was detected in 33.4% of cases; a definitive worsening resulted in 6% of cases. Patients with extent of resection of > 90% had an estimated 5-year overall survival rate of 92%, whereas those with extent of resection between 70% and 90% had a 5-year overall survival rate of 82% (P < .001). The difference between preoperative tumoral volumes on T2-weighted MRI and on postcontrast T1-weighted MRI ([T2 - T1] MRI volume) was computed to evaluate the role of the diffusive tumoral growing pattern on overall survival. Patients with preoperative volumetric difference < 30 cm demonstrated a 5-year overall survival rate of 92%, whereas those with a difference of > 30 cm had a 5-year overall survival rate of 57% (P = .02). CONCLUSION With intraoperative cortico-subcortical mapping and neurophysiological monitoring, a major resection is possible with an acceptable risk and a significant result in the follow-up.
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Affiliation(s)
- Miran Skrap
- Department of Neurosurgery, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine, Italy
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94
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Usefulness of thallium-201 SPECT for prediction of early progression in low-grade astrocytomas diagnosed by stereotactic biopsy. Clin Neurol Neurosurg 2012; 114:223-9. [DOI: 10.1016/j.clineuro.2011.10.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 10/17/2011] [Accepted: 10/20/2011] [Indexed: 11/21/2022]
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95
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Choi BD, Mehta AI, Batich KA, Friedman AH, Sampson JH. The Use of Motor Mapping to Aid Resection of Eloquent Gliomas. Neurosurg Clin N Am 2012; 23:215-25, vii. [DOI: 10.1016/j.nec.2012.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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96
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Ren X, Cui X, Lin S, Wang J, Jiang Z, Sui D, Li J, Wang Z. Co-deletion of chromosome 1p/19q and IDH1/2 mutation in glioma subsets of brain tumors in Chinese patients. PLoS One 2012; 7:e32764. [PMID: 22427879 PMCID: PMC3299680 DOI: 10.1371/journal.pone.0032764] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 02/02/2012] [Indexed: 11/21/2022] Open
Abstract
Objective To characterize co-deletion of chromosome 1p/19q and IDH1/2 mutation in Chinese brain tumor patients and to assess their associations with clinical features. Methods In a series of 528 patients with gliomas, pathological and radiological materials were reviewed. Pathological constituents of tumor subsets, incidences of 1p/19q co-deletion and IDH1/2 mutation in gliomas by regions and sides in the brain were analyzed. Results Overall, 1p and 19q was detected in 339 patients by FISH method while the sequence of IDH1/2 was determined in 280 patients. Gliomas of frontal, temporal and insular origin had significantly different pathological constituents of tumor subsets (P<0.001). Gliomas of frontal origin had significantly higher incidence of 1p/19q co-deletion (50.4%) and IDH1/2 mutation (73.5%) than those of non-frontal origin (27.0% and 48.5%, respectively) (P<0.001), while gliomas of temporal origin had significantly lower incidence of 1p/19q co-deletion (23.9%) and IDH1/2 mutation (41.7%) than those of non-temporal origin (39.9% and 63.2%, respectively) (P = 0.013 and P = 0.003, respectively). Subgroup analysis confirmed these findings in oligoastrocytic and oligodendroglial tumors, respectively. Although the difference of 1p/19q co-deletion was not statistically significant in temporal oligodendroglial tumors, the trend was marginally significant (P = 0.082). However, gliomas from different sides of the brain did not show significant different pathological constituents, incidences of 1p/19q co-deletion or IDH1/2 mutation. Conclusion Preferential distribution of pathological subsets, 1p/19q co-deletion and IDH1/2 mutation were confirmed in some brain regions in Chinese glioma patients, implying their distinctive tumor genesis and predictive value for prognosis.
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Affiliation(s)
- Xiaohui Ren
- Neurosurgery, Capital Medical University, Beijing Tiantan Hospital, Beijing, China
| | - Xiangli Cui
- Neurosurgery, Capital Medical University, Beijing Tiantan Hospital, Beijing, China
| | - Song Lin
- Neurosurgery, Capital Medical University, Beijing Tiantan Hospital, Beijing, China
- * E-mail:
| | - Junmei Wang
- Beijing Neurosurgical Institute, Beijing, China
| | - Zhongli Jiang
- Neurosurgery, Capital Medical University, Beijing Tiantan Hospital, Beijing, China
| | - Dali Sui
- Neurosurgery, Capital Medical University, Beijing Tiantan Hospital, Beijing, China
| | - Jing Li
- Neurosurgery, Capital Medical University, Beijing Tiantan Hospital, Beijing, China
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97
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Abstract
The insula is a functionally and anatomically complex cortical structure that can be affected by both low-grade and high-grade gliomas. This complexity often prevents many neurosurgeons from attempting to surgically manage insular gliomas. This article reviews the anatomic and functional uniqueness of the insula and the surgical outcomes and lessons learned from previously reported surgical series. Successful management of insular gliomas, defined as maximal resection of the tumor without postoperative neurologic morbidity, can be achieved through a sophisticated understanding of the neurovascular structure of the insular region and an intraoperative functional mapping using cortico-subcortical electrical stimulation.
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Affiliation(s)
- Young-Hoon Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, Korea
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98
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Hebb AO, Yang T, Silbergeld DL. The sub-pial resection technique for intrinsic tumor surgery. Surg Neurol Int 2011; 2:180. [PMID: 22368786 PMCID: PMC3267372 DOI: 10.4103/2152-7806.90714] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 11/02/2011] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The technique of sub-pial resection, first described in the early 1900s, was later refined by Penfield and Jasper for removal of supratentorial epileptic cortex. This technique has not been widely adopted for intrinsic tumor resection, for which the most widely used technique involves piecemeal aspiration of the tumor. This technique of "staying within the tumor" results in persistent bleeding, with obscuration of the tumor/brain interface, potentially yielding less than satisfactory results. In our experience, the sub-pial technique is useful for resections of supratentorial intrinsic tumor. We report the use of sub-pial resection technique and present illustrative cases. METHODS The sub-pial resection technique is described along with important clinical decision-making guidelines. Representative cases are presented to discuss application of the sub-pial technique and to demonstrate surgical results. RESULTS The sub-pial technique preserves the pia during cortical resections and makes it easier to protect and identify normal anatomy, including sulci, gyri, cranial nerves, and major vascular structures. This reduces bleeding, making surgery safer and more efficient. In most cases, an en bloc resection can be accomplished, permitting more accurate histopathology and more extensive tissue acquisition for research purposes. CONCLUSION The sub-pial technique can be incorporated into strategies for supratentorial intrinsic tumor resections, including temporal, frontal, occipital, and insular tumors, at para-Sylvian or para-insular-sulcus locations.
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Affiliation(s)
- Adam O Hebb
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA 98105, USA
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99
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Wu AS, Witgert ME, Lang FF, Xiao L, Bekele BN, Meyers CA, Ferson D, Wefel JS. Neurocognitive function before and after surgery for insular gliomas. J Neurosurg 2011; 115:1115-25. [DOI: 10.3171/2011.8.jns11488] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Insular gliomas can be resected with acceptable rates of neurological morbidity, but little is known with regard to impairment of higher-order neurocognitive functions. The frequency and functional impact of neurocognitive deficits in patients with gliomas has until recently been underappreciated. The authors therefore examined neurocognitive function in patients with insular gliomas and compared the findings in this group to those in a matched control group of patients with gliomas in nearby brain regions.
Methods
Thirty-three patients with WHO Grade II or III insular gliomas participated in neuropsychological evaluations before and after resection. To establish whether the pattern of neurocognitive performance was different from that of other patients with tumors in neighboring areas, patients with insular tumors were matched with control patients for age, educational level, preoperative Karnofsky Performance Scale score, tumor side, grade, and volume. The control group comprised patients in whom gliomas had been resected from frontal, temporal, and parietal areas near the insula. Baseline pre- and postoperative neurocognitive test results were compared between and within groups.
Results
Preoperative neurocognitive impairment was common in both insular and control groups. Patients with insular tumors had significantly worse preoperative performance on naming tests. In both groups, postoperative decline occurred in most neurocognitive domains. There were no statistically significant differences between patients in the insular and control groups with regard to rates of postoperative decline on any test. However, there were trends suggesting differential cognitive performance postoperatively, because patients with insular tumors were more likely to experience greater decline in learning and memory. Neurological morbidity was similar to prior rates reported in the literature.
Conclusions
Few statistically significant differences in cognitive function were observed between patients in the insular and control groups at either the pre- or postoperative evaluation, although there was a trend for patients with insular tumors to exhibit greater postoperative decline in learning and memory. Although technically more challenging, surgery for insular region glioma appears feasible without profound neurological or cognitive morbidity for many patients.
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Affiliation(s)
| | | | | | | | | | | | - David Ferson
- 4Anesthesiology and Perioperative Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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100
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Majchrzak K, Bobek-Billewicz B, Tymowski M, Adamczyk P, Majchrzak H, ładziński P. Surgical treatment of insular tumours with tractography, functional magnetic resonance imaging, transcranial electrical stimulation and direct subcortical stimulation support. Neurol Neurochir Pol 2011; 45:351-62. [DOI: 10.1016/s0028-3843(14)60106-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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