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Marino S, Dannhoff G, Destrieux C, Maldonado IL. Frontal trans opercular approaches to the insula: building the mental picture from procedure-guided anatomical dissection. Surg Radiol Anat 2024:10.1007/s00276-024-03409-7. [PMID: 38871860 DOI: 10.1007/s00276-024-03409-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 06/06/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Performing transopercular frontal approaches to the insula, widely used in glioma surgeries, necessitates a meticulous understanding of both cortical and subcortical neuroanatomy. This precision is vital for preserving essential structures and accurately interpreting the results of direct electrical stimulation. Nevertheless, acquiring a compelling mental image of the anatomy of this region can be challenging due to several factors, among which stand out its complexity and the fact that white matter fasciculi are imperceptible to the naked eye in the living brain. AIM In an effort to optimize the study of the anatomy relevant to this topic, we performed a procedure-guided laboratory study using subpial dissection, fiber dissection, vascular coloration, and stereoscopic photography in a "real-life" surgical perspective. METHODS Nine cerebral specimens obtained from body donation were extracted and fixed in formalin. Colored silicone injection and a variant of Klinglers's technique were used to demonstrate vascular and white matter structures, respectively. We dissected and photographed the specimens in a supero-antero-lateral view to reproduce the surgeon's viewpoint. The anatomy related to the development of the surgical corridor and resection cavity was documented using both standard photography and the red-cyan anaglyph technique. RESULTS The anatomy of frontal transopercular approaches to the insula involved elements of different natures-leptomeningeal, cortical, vascular, and fascicular-combining in the surgical field in a complex disposition. The disposition of these structures was successfully demonstrated through the aforementioned anatomical techniques. Among the main structures in or around the surgical corridor, the orbital, triangular, and opercular portions of the inferior frontal gyrus are critical landmarks in the cortical stage, as well as the leptomeninges of the Sylvian fissure and the M2-M4 branches of the middle cerebral artery in the subpial dissection stage, and the inferior fronto-occipital, uncinate and arcuate fasciculi, and the corona radiata in establishing the deep limits of resection. CONCLUSIONS Procedure-guided study of cerebral hemispheres associating subpial, vascular, and fiber dissection from a surgical standpoint is a powerful tool for the realistic study of the surgical anatomy relevant to frontal transopercular approaches to the insula.
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Affiliation(s)
- Salvatore Marino
- Department of Neuroscience, Neurosurgery Section, Università Cattolica del Sacro Cuore, Rome, Italy
- INSERM, Imaging Brain & Neuropsychiatry iBraiN U1253, Université de Tours, Tours, France
| | - Guillaume Dannhoff
- INSERM, Imaging Brain & Neuropsychiatry iBraiN U1253, Université de Tours, Tours, France
- CHRU de Strasbourg, Strasbourg, France
| | - Christophe Destrieux
- INSERM, Imaging Brain & Neuropsychiatry iBraiN U1253, Université de Tours, Tours, France
- CHRU de Tours, Tours, France
| | - Igor Lima Maldonado
- INSERM, Imaging Brain & Neuropsychiatry iBraiN U1253, Université de Tours, Tours, France.
- CHRU de Tours, Tours, France.
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2
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Xue B, Hou Z, Deng Z, Sun S, Zhang C, Pan Y, Zhang Y, Li Z, Xie J. Survival outcome and predictors of WHO grade 2 and 3 insular gliomas: A classification based on the tumor spread. Cancer Med 2024; 13:e7377. [PMID: 38850123 PMCID: PMC11161818 DOI: 10.1002/cam4.7377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 04/06/2024] [Accepted: 05/27/2024] [Indexed: 06/09/2024] Open
Abstract
OBJECTIVE The study aimed to identify if clinical features and survival outcomes of insular glioma patients are associated with our classification based on the tumor spread. METHODS Our study included 283 consecutive patients diagnosed with histological grade 2 and 3 insular gliomas. A new classification was proposed, and tumors restricted to the paralimbic system were defined as type 1. When tumors invaded the limbic system (referred to as the hippocampus and its surrounding structures in this study) simultaneously, they were defined as type 2. Tumors with additional internal capsule involvement were defined as type 3. RESULTS Tumors defined as type 3 had a higher age at diagnosis (p = 0.002) and a higher preoperative volume (p < 0.001). Furthermore, type 3 was more likely to be diagnosed as IDH wild type (p < 0.001), with a higher rate of Ki-67 index (p = 0.015) and a lower rate of gross total resection (p < 0.001). Type 1 had a slower tumor growth rate than type 2 (mean 3.3%/month vs. 19.8%/month; p < 0.001). Multivariate Cox regression analysis revealed the extent of resection (HR 0.259, p = 0.004), IDH status (HR 3.694, p = 0.012), and tumor spread type (HR = 1.874, p = 0.012) as independent predictors of overall survival (OS). Tumor grade (HR 2.609, p = 0.008), the extent of resection (HR 0.488, p = 0.038), IDH status (HR 2.225, p = 0.025), and tumor spread type (HR 1.531, p = 0.038) were significant in predicting progression-free survival (PFS). CONCLUSION The current study proposes a classification of the insular glioma according to the tumor spread. It indicates that the tumors defined as type 1 have a relatively better nature and biological characteristics, and those defined as type 3 can be more aggressive and refractory. Besides its predictive value for prognosis, the classification has potential value in formulating surgical strategies for patients with insular gliomas.
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Affiliation(s)
- Bowen Xue
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Zonggang Hou
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Zhenghai Deng
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Shengjun Sun
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Department of RadiologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Chuanhao Zhang
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Yuesong Pan
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Yazhuo Zhang
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Beijing Neurosurgical Institute, Capital Medical UniversityBeijingChina
| | - Zhenye Li
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Jian Xie
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
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3
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Biswas C, Shetty PM, Sahu A, Velayutham P, Singh V, Shah K, Moiyadi AV. Factors affecting the extent of resection and neurological outcomes following transopercular resection of insular gliomas. Acta Neurochir (Wien) 2024; 166:244. [PMID: 38822919 PMCID: PMC11144144 DOI: 10.1007/s00701-024-06124-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/14/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Surgical resection of insular gliomas is a challenge. TO resection is considered more versatile and has lower risk of vascular damage. In this study, we aimed to understand the factors that affect resection rates, ischemic changes and neurological outcomes and studied the utility of IONM in patients who underwent TO resection for IGs. METHODS Retrospective analysis of 66 patients with IG who underwent TO resection was performed. RESULTS Radical resection was possible in 39% patients. Involvement of zone II and the absence of contrast enhancement predicted lower resection rate. Persistent deficit rate was 10.9%. Although dominant lobe tumors increased immediate deficit and fronto-orbital operculum involvement reduced prolonged deficit rate, no tumor related factor showed significant association with persistent deficits. 45% of patients developed a postoperative infarct, 53% of whom developed deficits. Most affected vascular territory was lenticulostriate (39%). MEP changes were observed in 9/57 patients. 67% of stable TcMEPs and 74.5% of stable strip MEPs did not develop any postoperative motor deficits. Long-term deficits were seen in 3 and 6% patients with stable TcMEP and strip MEPs respectively. In contrast, 25% and 50% of patients with reversible strip MEP and Tc MEP changes respectively had persistent motor deficits. DWI changes were clinically more relevant when accompanied by MEP changes intraoperatively, with persistent deficit rates three times greater when MEP changes occurred than when MEPs were stable. CONCLUSION Radical resection can be achieved in large, multizone IGs, with reasonable outcomes using TO approach and multimodal intraoperative strategy with IONM.
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Affiliation(s)
- Chandrima Biswas
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Prakash M Shetty
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Arpita Sahu
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
- Department of Radiodiagnosis, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Parthiban Velayutham
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vikas Singh
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Kanchi Shah
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Aliasgar V Moiyadi
- Neurosurgical Services, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India.
- Department of Health Sciences, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
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Nichols NM, Ezzat B, Waters AC, Panov F, Yong RL, Germano IM. What is the cognitive footprint of insular glioma? Front Hum Neurosci 2024; 18:1382380. [PMID: 38859993 PMCID: PMC11163043 DOI: 10.3389/fnhum.2024.1382380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/29/2024] [Indexed: 06/12/2024] Open
Abstract
Cognitive impairment has a profound deleterious impact on long-term outcomes of glioma surgery. The human insula, a deep cortical structure covered by the operculum, plays a role in a wide range of cognitive functions including interceptive thoughts and salience processing. Both low-grade (LGG) and high-grade gliomas (HGG) involve the insula, representing up to 25% of LGG and 10% of HGG. Surgical series from the past 30 years support the role of primary cytoreductive surgery for insular glioma patients; however, reported cognitive outcomes are often limited to speech and language function. The breath of recent neuroscience literature demonstrates that the insula plays a broader role in cognition including interoceptive thoughts and salience processing. This article summarizes the vast functional role of the healthy human insula highlighting how this knowledge can be leveraged to improve the care of patients with insular gliomas.
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Affiliation(s)
- Noah M Nichols
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, United States
| | - Bahie Ezzat
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, United States
- School of Medicine, Mount Sinai School of Medicine, New York, NY, United States
| | - Allison C Waters
- Department of Neuroscience, Mount Sinai School of Medicine, New York, NY, United States
| | - Fedor Panov
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, United States
| | - Raymund L Yong
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, United States
| | - Isabelle M Germano
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, United States
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5
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Simon M, Hagemann A, Gajadin S, Signorelli F, Vincent AJ. Surgical treatment for insular gliomas. A systematic review and meta-analysis on behalf of the EANS neuro-oncology section. BRAIN & SPINE 2024; 4:102828. [PMID: 38859917 PMCID: PMC11163152 DOI: 10.1016/j.bas.2024.102828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 06/12/2024]
Abstract
Introduction The appropriate surgical management of insular gliomas is controversial. Management strategies vary considerably between centers. Research question To provide robust resection, functional and epilepsy outcome figures, study growth patterns and tumor classification paradigms, analyze surgical approaches, mapping/monitoring strategies, surgery for insular glioblastoma, as well as molecular findings, and to identify open questions for future research. Material and methods On behalf of the EANS Neuro-oncology Section we performed a systematic review and meta-analysis (using a random-effects model) of the more current (2000-2023) literature in accordance with the PRISMA guidelines. Results The pooled postoperative motor and speech deficit rates were 6.8% and 3.6%. There was a 79.6% chance for postoperative epilepsy control. The postoperative KPI was 80-100 in 83.5% of cases. Functional monitoring/mapping paradigms (which may include awake craniotomies) seem mandatory. (Additional) awake surgery may result in slightly better functional but also worse resection outcomes. Transcortical approaches may carry a lesser rate of (motor) deficits than transsylvian surgeries. Discussion and conclusions This paper provides an inclusive overview and analysis of current surgical management of insular gliomas. Risks and complication rates in experienced centers do not necessarily compare unfavorably with the results of routine neuro-oncological procedures. Limitations of the current literature prominently include a lack of standardized outcome reporting. Questions and issues that warrant more attention include surgery for insular glioblastomas and how to classify the various growth patterns of insular gliomas.
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Affiliation(s)
- Matthias Simon
- Dept. of Neurosurgery, Bethel Clinic, University of Bielefeld Medical Center OWL, Bielefeld, Germany
| | | | - Sanjana Gajadin
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Francesco Signorelli
- Division of Neurosurgery, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University "Aldo Moro", Bari, Italy
| | - Arnaud J.P.E. Vincent
- Division of Neurosurgery, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University "Aldo Moro", Bari, Italy
| | - for the EANS Neuro-oncology Section
- Dept. of Neurosurgery, Bethel Clinic, University of Bielefeld Medical Center OWL, Bielefeld, Germany
- Society for Epilepsy Research, Bielefeld, Germany
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
- Division of Neurosurgery, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University "Aldo Moro", Bari, Italy
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Toyoda M, Shibahara I, Kumabe T. Trans-Sylvian and Transanterior Ascending Ramus Approach for Insular Gliomas at Zone I: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01148. [PMID: 38687038 DOI: 10.1227/ons.0000000000001197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/18/2024] [Indexed: 05/02/2024] Open
Abstract
Insular gliomas present significant challenges because of their deep-seated location and proximity to critical structures, including Sylvian veins, middle cerebral arteries, lenticulostriate arteries,1 long insular arteries,2 and functional cortices.3-6 The Berger-Sanai classification categorizes them into 4 zones (I-IV), providing a framework for understanding insular gliomas.7 The key factors for successful insular glioma removal are achieving the greatest insular exposure and surgical freedom.3 Given that the trans-Sylvian approach8,9 creates a narrow, linear surgical window,3 regardless of the zones, various surgical options have been employed, such as the trans-Sylvian approach with bridging vein cuts and the transcortical approach through functionally silent cortex.3,7,9-13 Dissecting sulci in glioma surgeries has proven beneficial.14-16 In this video publication, we dissected the anterior ascending ramus (AAR) and the Sylvian fissure, creating a triangular window instead of a linear one. A 74-year-old right-handed woman with a zone I insular glioma underwent a trans-Sylvian and trans-AAR approach, achieving total resection of the tumor without new neurological deficits. This approach provided maximum exposure of the insular region, offering a wide view from the anterior limiting sulcus to the anterior half of the superior limiting sulcus of the insula. The histological diagnosis revealed a rare adult pilocytic astrocytoma at the insula, documented in only one case report.17 The AAR,4 defined as a lateral sulcus (Sylvian fissure) branch,18 is present in 98.89% of hemispheres19; therefore, this surgical approach demonstrates broad applicability to zone I insular tumors. The patient provided consent for the procedure and the publication of her image under institutional review board approval (G23-08).
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Affiliation(s)
- Mariko Toyoda
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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Hoz SS, Ismail M, Palmisciano P, Al-Khazaali YM, Saleh SA, Muthana A, Forbes JA, Prestigiacomo CJ, Zuccarello M, Andaluz N. Cortical incisions and transcortical approaches for intra-axial and intraventricular lesions: A scoping review. Surg Neurol Int 2024; 15:82. [PMID: 38628541 PMCID: PMC11021096 DOI: 10.25259/sni_58_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/11/2024] [Indexed: 04/19/2024] Open
Abstract
Background Transcortical approaches, encompassing various surgical corridors, have been employed to treat an array of intraparenchymal or intraventricular brain pathologies, including tumors, vascular malformations, infections, intracerebral hematomas, and epileptic surgery. Designing cortical incisions relies on the lesion location and characteristics, knowledge of eloquent functional anatomy, and advanced imaging such as tractography. Despite their widespread use in neurosurgery, there is a noticeable lack of systematic studies examining their common lobe access points, associated complications, and prevalent pathologies. This scoping review assesses current evidence to guide the selection of transcortical approaches for treating a variety of intracranial pathologies. Methods A scoping review was conducted using the PRISMA-ScR guidelines, searching PubMed, EMBASE, Scopus, and Web of Science. Studies were included if ≥5 patients operated on using transcortical approaches, with reported data on clinical features, treatments, and outcomes. Data analysis and synthesis were performed. Results A total of 50 articles encompassing 2604 patients were included in the study. The most common primary pathology was brain tumors (60.6%), particularly gliomas (87.4%). The transcortical-transtemporal approach was the most frequently identified cortical approach (70.48%), and the temporal lobe was the most accessed brain lobe (55.68%). The postoperative course outcomes were reported as good (55.52%), poor (28.38%), and death (14.62%). Conclusion Transcortical approaches are crucial techniques for managing a wide range of intracranial lesions, with the transcortical-transtemporal approach being the most common. According to the current literature, the selective choice of cortical incision and surgical corridor based on the lesion's pathology and anatomic-functional location correlates with acceptable functional outcomes.
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Affiliation(s)
- Samer S. Hoz
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, United States
| | - Mustafa Ismail
- Department of Neurosurgery, University of Baghdad, College of Medicine, Baghdad, Iraq
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati, Cincinnati, United States
| | | | - Saleh A. Saleh
- Department of Neurosurgery, University of Baghdad, Baghdad, Iraq
| | - Ahmed Muthana
- Department of Neurosurgery, University of Baghdad, College of Medicine, Baghdad, Iraq
| | - Jonathan A. Forbes
- Department of Neurosurgery, University of Cincinnati, Cincinnati, United States
| | | | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati, Cincinnati, United States
| | - Norberto Andaluz
- Department of Neurosurgery, University of Cincinnati, Cincinnati, United States
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8
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Papadopoulou A, Kumar NS. Prognostic Factors and Resectability Predictors in Insular Gliomas: A Systematic Review. J Neurol Surg A Cent Eur Neurosurg 2024; 85:74-87. [PMID: 37619597 PMCID: PMC10764153 DOI: 10.1055/s-0043-1769128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 04/03/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Insular gliomas (INGs) remain a surgically intimidating glioma subgroup encased by eloquent cortical parcels and white matter language tracts, and traversed by multiple middle cerebral artery branches. The predictive power of prognostic factors affecting overall survival (OS), progression-free survival (PFS), and resectability of INGs remain disputed. This comprehensive systematic review analyses prognostic factors and resectability predictors of INGs substantiating pragmatic management options. MATERIALS AND METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) and the Cochrane Handbook of Systematic Reviews of Interventions guidelines. The PubMed, MEDLINE, and Embase databases were searched in April 2022. All clinical studies with ≥10 patients harboring INGs with any intervention and reporting predictors of OS, PFS, and tumor resectability in INGs were included. Molecular ING prognosticators were also included. Studies combining insular and other gliomas analysis, case studies, experimental and animal studies, conference abstracts, letters to the editor, and articles in other languages were excluded. RESULTS Of the 2,384 articles returned, 27 fulfilled the inclusion criteria totaling 1,985 patients. The review yielded 18 OS and 17 PFS prognosticators. These were classified as preoperative (radiologic; clinical), intraoperative, and postoperative (molecular; histopathologic; clinical) prognosticators. In addition, 21 resectability predictors were categorized as preoperative (radiologic; clinical), intraoperative (surgical approach and assistive technology), and postoperative (histopathologic; clinical). The quality assessment revealed 24/27 studies had low risk of bias. One study with moderate and two studies with high risk of bias were included. CONCLUSION Negative prognosticators reported in ≥2 studies included putaminal or paralimbic involvement and higher tumor grade, while seizures at presentation, isocitrate dehydrogenase (IDH) mutation, increased extent of resection, and higher Karnofsky Performance Status preoperatively and at 3 months postoperation were positive prognosticators. Resectability predictors reported in ≥2 studies included the positive predictors of zone I/zone IV tumor location and intraoperative imaging use and the negative predictor of encased lenticulostriate arteries. Paralimbic INGs are not a single entity with homogeneous prognosis. Integration of identified prognosticators in a prospective trial to devise a grading system for INGs can improve clinical decision-making.
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Affiliation(s)
- Ariadni Papadopoulou
- Division of Medicine, University College London Medical School, London, United Kingdom of Great Britain and Northern Ireland
| | - Niraj S. Kumar
- Division of Medicine, University College London Medical School, London, United Kingdom of Great Britain and Northern Ireland
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Sun GC, Shu XJ, Zheng XQ, Ma XD, Cheng G, Liu JL, Chen L, Zhang JN. The transfrontal isthmus approach for insular glioma surgery. J Neurosurg 2022:1-9. [PMID: 36681987 DOI: 10.3171/2022.8.jns22923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 08/09/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The classic transopercular or transsylvian approach to insular gliomas removes the tumor laterally through the insular cortex. This study describes a new anteroposterior approach through the frontal isthmus for insular glioma surgery. METHODS The authors detailed the surgical techniques for resection of insular gliomas through the transfrontal isthmus approach. Fifty-nine insular gliomas with at least Berger-Sanai zone I involvement were removed with the new approach, and extent of resection and postoperative neurological outcomes were assessed. RESULTS Fifty-nine patients were enrolled in the study, including 35 men and 24 women, with a mean (range) age 44.3 (19-75) years. According to the Berger-Sanai classification system, the most common tumor was a giant glioma (67.8%), followed by involvement of zones I and IV (18.6%). Twenty-two cases were Yaşargil type 3A/B, and 37 cases were Yaşargil type 5A/B. The average angle between the lateral plane of the putamen and sagittal line was 33.53°, and the average width of the isthmus near the anterior insular point was 33.33 mm. The average angle between the lateral plane of the putamen and the sagittal line was positively correlated with the width of the isthmus near the anterior insular point (r = 0.935, p < 0.0001). The median (interquartile range [IQR]) preoperative tumor volume was 67.82 (57.64-92.19) cm3. Of 39 low-grade gliomas, 26 (66.67%) were totally resected; of 20 high-grade gliomas, 19 (95%) were totally resected. The median (IQR) extent of resection of the whole group was 100% (73.7%-100%). Intraoperative diffusion-weighted imaging showed no cases of middle cerebral artery- or lenticulostriate artery-related stroke. Extent of insular tumor resection was positively correlated with the angle of the lateral plane of the putamen and sagittal line (r = -0.329, p = 0.011) and the width of the isthmus near the anterior insular point (r = -0.267, p = 0.041). At 3 months postoperatively, muscle strength grade exceeded 4 in all cases, and all patients exhibited essentially normal speech. The median (IQR) Karnofsky performance score at 3 months after surgery was 90 (80-90). CONCLUSIONS The transfrontal isthmus approach changes the working angle from lateral-medial to anterior-posterior, allowing for maximal safe removal of insular gliomas.
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Affiliation(s)
- Guo-Chen Sun
- Neurosurgery, The First Medical Center of PLA General Hospital, Beijing, China
| | - Xu-Jun Shu
- Neurosurgery, The First Medical Center of PLA General Hospital, Beijing, China
| | - Xiao-Que Zheng
- Neurosurgery, The First Medical Center of PLA General Hospital, Beijing, China
| | - Xiao-Dong Ma
- Neurosurgery, The First Medical Center of PLA General Hospital, Beijing, China
| | - Gang Cheng
- Neurosurgery, The First Medical Center of PLA General Hospital, Beijing, China
| | - Jia-Lin Liu
- Neurosurgery, The First Medical Center of PLA General Hospital, Beijing, China
| | - Ling Chen
- Neurosurgery, The First Medical Center of PLA General Hospital, Beijing, China
| | - Jian-Ning Zhang
- Neurosurgery, The First Medical Center of PLA General Hospital, Beijing, China
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10
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Hou Z, Huang Z, Li Z, Deng Z, Li G, Xu Y, Wang M, Sun S, Zhang Y, Qiao H, Xie J. Incidence of ischemic complications and technical nuances of arteries preservation for insular gliomas resection. Front Surg 2022; 9:956872. [PMID: 36311934 PMCID: PMC9614341 DOI: 10.3389/fsurg.2022.956872] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/12/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Insular gliomas have complex anatomy and microvascular supply that make resection difficult. Furthermore, resection of insular glioma is associated with a significant risk of postoperative ischemic complications. Thus, this study aimed to assess the incidence of ischemic complications related to insular glioma resection, determine its risk factors, and describe a single surgeon's experience of artery-preserving tumor resection. Methods We enrolled 75 consecutive patients with insular gliomas who underwent transcortical tumor resection. Preoperative and postoperative demographic, clinical, radiological [including diffusion-weighted imaging (DWI)], intraoperative neurophysiological data, and functional outcomes were analyzed. Motor evoked potentials (MEPs) and radiological characteristics like the relationship between the proximal segment of the lateral lenticulostriate arteries (LLSAs) and the tumor, the flat inner edge sign (the inner edge of the insular glioma is well-defined) or obscure inner edge sign, the distance between the lesion and posterior limb of the internal capsule and the invasion of the superior limiting sulcus by the tumor were analyzed. Strategies such as "residual triangle," "basal ganglia outline reappearance," and "sculpting" technique were used to preserve the LLSAs and the main branches of M2 for maximal tumor resection according to the Berger-Sinai classification. Results Postoperative DWI showed acute ischemia in 44 patients (58.7%). Moreover, nine patients (12%) had developed new motor deficits, as determined by the treating neurosurgeons. The flat inner edge sign [odds ratio (OR), 0.144; 95% confidence interval (CI), 0.024-0.876) and MEPs (>50%) (OR, 18.182; 95% CI, 3.311-100.00) were significantly associated with postoperative core ischemia, which affected the posterior limb of the internal capsule or corona radiata. Conclusions Insular glioma resection was associated with a high incidence of ischemia, as detected by DWI, as well as new motor deficits that were determined by the treating neurosurgeons. Insular glioma patients with obscure inner edge signs and intraoperative MEPs decline >50% had a higher risk of developing core ischemia. With our strategies, maximal safe resection of insular gliomas may be achieved.
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Affiliation(s)
- Zonggang Hou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhenxing Huang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhenye Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhenghai Deng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gen Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yaokai Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingran Wang
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Shengjun Sun
- Neuroimaging Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Hui Qiao
- Department of Neurophysiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China,Correspondence: Jian Xie Hui Qiao
| | - Jian Xie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,Correspondence: Jian Xie Hui Qiao
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11
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Duffau H. Awake Mapping With Transopercular Approach in Right Insular-Centered Low-Grade Gliomas Improves Neurological Outcomes and Return to Work. Neurosurgery 2022; 91:182-190. [PMID: 35445665 DOI: 10.1227/neu.0000000000001966] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 02/05/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Asleep vs awake surgery for right insula-centered low-grade glioma (LGG) is still debated. OBJECTIVE To compare neurological outcomes and return to work after resection for right insular/paralimbic LGG performed without vs with awake mapping. METHODS A personal surgical experience of right insula-centered LGG was analyzed, by comparing 2 consecutive periods. In the first period (group 1), patients underwent asleep surgery with motor mapping. In the second period (group 2), patients underwent intraoperative awake mapping of movement and cognitive functions. RESULTS This consecutive series included 143 LGGs: 41 in group 1 (1999-2009) and 102 in group 2 (2009-2020). There were no significant difference concerning preoperative clinicoradiological characteristics and histopathology results between both groups. Intraoperative motor mapping was positive in all cases in group 1. In group 2, beyond motor mapping, somatosensory, visuospatial, language, and/or cognitive functions were identified during cortical-subcortical stimulation. Postoperatively, 3 patients experienced a long-lasting deterioration with 2 hemiparesis due to deep stroke (1.3%) and 1 severe depressive syndrome, all of them in group 1 vs none in group 2 (P = .022). The rate of RTW was 81.5% in group 1 vs 95.5% in group 2 (P = .016). The tumor volume and extent of resection did not significantly differ across both groups. CONCLUSION This is the first study comparing asleep vs awake surgery for right insula-centered LGG. Despite similar extent of resection, functional outcomes were significantly better in awake patients by avoiding permanent neurological impairment and by increasing RTW. These results support the mapping of higher-order functions during awake procedure.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.,Team "Plasticity of Central Nervous System, Stem Cells and Low-grade gliomas," INSERM U1191, Institute of Functional Genomics, University of Montpellier, Montpellier, France
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12
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Sun GC, Zhao K, Shu XJ, Liu RY, Dong MX, Chen XL, Xu BN. Resection of Insular Glioma Through the Transfrontal Limiting Sulcus Approach. Oper Neurosurg (Hagerstown) 2022; 22:400-408. [DOI: 10.1227/ons.0000000000000146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/14/2021] [Indexed: 11/18/2022] Open
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13
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Duffau H. Awake Surgery for Left Posterior Insular Low-Grade Glioma Through the Parietorolandic Operculum: The Need to Preserve the Functional Connectivity. A Case Series. Front Surg 2022; 8:824003. [PMID: 35096960 PMCID: PMC8792505 DOI: 10.3389/fsurg.2021.824003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 12/10/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Surgical approach to low-grade glioma (LGG) involving the posterior insula is challenging, especially in the left hemisphere, with a high risk of sensorimotor, language, or visual deterioration. In this study, a case series of 5 right-handed patients harboring a left posterior insular LGG is reported, by detailing a transcorticosubcortical approach.Method: The five surgeries were achieved in awake patients using cortical and axonal electrostimulation mapping. The glioma was removed through the left rolandic and/or parietal opercula, with preservation of the subcortical connectivity.Results: The cortical mapping was positive in the five patients, enabling the selection of an optimal transcortical approach, via the anterolateral supramarginal gyrus in four patients and/or via the lateral retrocentral gyrus in three cases (plus through the left superior temporal gyrus in one case). Moreover, the white matter tracts were identified in all cases, i.e., the lateral part of the superior longitudinal fasciculus (five cases), the arcuate fasciculus (four cases), the thalamocortical somatosensory pathways (four cases), the motor pathway (one case), the semantic pathway (three cases), and the optic tract (one case). Complete resection of the LGG was achieved in two patients and near-total resection in three patients. There were no postoperative permanent sensorimotor, language, or visual deficits.Conclusion: A transcortical approach through the parietorolandic operculum in awake patients represents safe and effective access to the left posterior insular LGG. Detection and preservation of the functional connectivity using direct electrostimulation of the white matter bundles are needed in this cross-road brain region to prevent otherwise predictable postsurgical impairments.
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Affiliation(s)
- Hugues Duffau
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Team “Plasticity of Central Nervous System, Stem Cells and Glial Tumors, ” National Institute for Health and Medical Research (INSERM), U1191 Laboratory, Institute of Functional Genomics, University of Montpellier, Montpellier, France
- *Correspondence: Hugues Duffau
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14
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Pallud J, Roux A, Trancart B, Peeters S, Moiraghi A, Edjlali M, Oppenheim C, Varlet P, Chrétien F, Dhermain F, Zanello M, Dezamis E. Surgery of Insular Diffuse Gliomas-Part 2: Probabilistic Cortico-Subcortical Atlas of Critical Eloquent Brain Structures and Probabilistic Resection Map During Transcortical Awake Resection. Neurosurgery 2021; 89:579-590. [PMID: 34383936 DOI: 10.1093/neuros/nyab255] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/12/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Insular diffuse glioma surgery is challenging, and tools to help surgical planning could improve the benefit-to-risk ratio. OBJECTIVE To provide a probabilistic resection map and frequency atlases of critical eloquent regions of insular diffuse gliomas based on our surgical experience. METHODS We computed cortico-subcortical "eloquent" anatomic sites identified intraoperatively by direct electrical stimulations during transcortical awake resection of insular diffuse gliomas in adults. RESULTS From 61 insular diffuse gliomas (39 left, 22 right; all left hemispheric dominance for language), we provided a frequency atlas of eloquence of the opercula (left/right; pars orbitalis: 0%/5.0%; pars triangularis: l5.6%/4.5%; pars opercularis: 37.8%/27.3%; precentral gyrus: 97.3%/95.4%; postcentral and supramarginal gyri: 75.0%/57.1%; temporal pole and superior temporal gyrus: 13.3%/0%), which tailored the transcortical approach (frontal operculum to reach the antero-superior insula, temporal operculum to reach the inferior insula, parietal operculum to reach the posterior insula). We provided a frequency atlas of eloquence identifying the subcortical functional boundaries (36.1% pyramidal pathways, 50.8% inferior fronto-occipital fasciculus, 13.1% arcuate and superior longitudinal fasciculi complex, 3.3% somatosensory pathways, 8.2% caudate and lentiform nuclei). Vascular boundaries and increasing errors during testing limited the resection in 8.2% and 11.5% of cases, respectively. We provided a probabilistic 3-dimensional atlas of resectability. CONCLUSION Functional mapping under awake conditions has to be performed intraoperatively in each patient to guide surgical approach and resection of insular diffuse gliomas in right and left hemispheres. Frequency atlases of opercula eloquence and of subcortical eloquent anatomic boundaries, and probabilistic 3-dimensional atlas of resectability could guide neurosurgeons.
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Affiliation(s)
- Johan Pallud
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Alexandre Roux
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Bénédicte Trancart
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Sophie Peeters
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Alessandro Moiraghi
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Myriam Edjlali
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.,Department of Neuroradiology, GHU Paris - Sainte-Anne Hospital, Paris, France
| | - Catherine Oppenheim
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.,Department of Neuroradiology, GHU Paris - Sainte-Anne Hospital, Paris, France
| | - Pascale Varlet
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France.,Department of Neuropathology, GHU Paris - Sainte-Anne Hospital, Paris, France
| | - Fabrice Chrétien
- Université de Paris, Sorbonne Paris Cité, Paris, France.,Department of Neuropathology, GHU Paris - Sainte-Anne Hospital, Paris, France
| | - Frédéric Dhermain
- Department of Radiotherapy, Gustave Roussy University Hospital, Villejuif, France
| | - Marc Zanello
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
| | - Edouard Dezamis
- Department of Neurosurgery, GHU Paris - Sainte-Anne Hospital, Paris, France.,Université de Paris, Sorbonne Paris Cité, Paris, France.,Inserm, U1266, IMA-Brain, Institut de Psychiatrie et Neurosciences de Paris, Paris, France
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15
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Dziedzic TA, Bala A, Marchel A. Anatomical aspects of the insula, opercula and peri-insular white matter for a transcortical approach to insular glioma resection. Neurosurg Rev 2021; 45:793-806. [PMID: 34292438 PMCID: PMC8827298 DOI: 10.1007/s10143-021-01602-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/16/2021] [Accepted: 06/29/2021] [Indexed: 11/01/2022]
Abstract
The insula is a lobe located deep in each hemisphere of the brain and is surrounded by eloquent cortical, white matter, and basal ganglia structures. The aim of this study was to provide an anatomical description of the insula and white matter tracts related to surgical treatment of gliomas through a transcortical approach. The study also discusses surgical implications in terms of intraoperative brain mapping. Five adult brains were prepared according to the Klingler technique. Cortical anatomy was evaluated with the naked eye, whereas white matter dissection was performed with the use of a microscope. The widest exposure of the insular surface was noted through the temporal operculum, mainly in zones III and IV according to the Berger-Sanai classification. By going through the pars triangularis in all cases, the anterior insular point and most of zone I were exposed. The narrowest and deepest operating field was observed by going through the parietal operculum. This method provided a suitable approach to zone II, where the corticospinal tract is not covered by the basal ganglia and is exposed just under the superior limiting sulcus. At the subcortical level, the identification of the inferior frontoocipital fasciculus at the level of the limen insulae is critical in terms of preserving the lenticulostriate arteries. Detailed knowledge of the anatomy of the insula and subcortical white matter that is exposed through each operculum is essential in preoperative planning as well as in the intraoperative decision-making process in terms of intraoperative brain mapping.
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Affiliation(s)
- Tomasz Andrzej Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Banacha 1a, 02-097, Warszawa, Poland.
| | - Aleksandra Bala
- Department of Neurosurgery, Medical University of Warsaw, Banacha 1a, 02-097, Warszawa, Poland.,Faculty of Psychology, University of Warsaw, Warsaw, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Banacha 1a, 02-097, Warszawa, Poland
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16
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Huang Z, Li G, Li Z, Sun S, Zhang Y, Hou Z, Xie J. Contralesional Structural Plasticity in Different Molecular Pathologic Subtypes of Insular Glioma. Front Neurol 2021; 12:636573. [PMID: 33935941 PMCID: PMC8079625 DOI: 10.3389/fneur.2021.636573] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/08/2021] [Indexed: 12/25/2022] Open
Abstract
Neuroplasticity may preserve neurologic function in insular glioma, thereby improving prognosis following resection. However, the anatomic and molecular bases of this phenomenon are not known. To address this gap in knowledge, the present study investigated contralesional compensation in different molecular pathologic subtypes of insular glioma by high-resolution three-dimensional T1-weighted structural magnetic resonance imaging. A total of 52 patients with insular glioma were examined. We compared the gray matter volume (GMV) of the contralesional insula according to histological grade [low-grade glioma (LGG) and high-grade glioma (HGG)] and molecular pathology status [isocitrate dehydrogenase (IDH) mutation, telomerase reverse-transcriptase (TERT) promoter mutation, and 1p19q codeletion] by voxel-based morphometry (VBM). A cluster of 320 voxels in contralesional insula with higher GMV was observed in glioma with IDH mutation as compared to IDH wild-type tumors by region of interest-based VBM analysis (family-wise error-corrected at p < 0.05). The GMV of the entire contralesional insula was also larger in insular glioma patients with IDH mutation than in patients with wild-type IDH. However, there was no association between histological grade, TERT promoter mutation, or 1p19q codeletion and GMV in the contralesional insula. Thus, IDH mutation is associated with greater structural compensation in insular glioma. These findings may be useful for predicting neurocognitive and functional outcomes in patients undergoing resection surgery.
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Affiliation(s)
- Zhenxing Huang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Gen Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Zhenye Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Shengjun Sun
- China National Clinical Research Centre for Neurological Diseases, Beijing, China.,Neuroimaging Center, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yazhuo Zhang
- China National Clinical Research Centre for Neurological Diseases, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Zonggang Hou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Jian Xie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Centre for Neurological Diseases, Beijing, China
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17
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Rossi M, Gay L, Conti Nibali M, Sciortino T, Ambrogi F, Leonetti A, Puglisi G, Howells H, Zito P, Villa F, Ciroi G, Riva M, Bello L. Challenging Giant Insular Gliomas With Brain Mapping: Evaluation of Neurosurgical, Neurological, Neuropsychological, and Quality of Life Results in a Large Mono-Institutional Series. Front Oncol 2021; 11:629166. [PMID: 33828981 PMCID: PMC8019925 DOI: 10.3389/fonc.2021.629166] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/01/2021] [Indexed: 01/23/2023] Open
Abstract
Objective Giant insular tumors are commonly not amenable to complete resection and are associated with a high postoperative morbidity rate. Transcortical approach and brain mapping techniques allow to identify peri-insular functional networks and, with neurophysiological monitoring, to reduce vascular-associated insults. Cognitive functions to be mapped are still under debate, and the analysis of the functional risk of surgery is currently limited to neurological examination. This work aimed to investigate the neurosurgical outcome (extent of resection, EOR) and functional impact of giant insular gliomas resection, focusing on neuropsychological and Quality of Life (QoL) outcomes. Methods In our retrospective analysis, we included all patients admitted in a five-year period with a radiological diagnosis of giant insular glioma. A transcortical approach was adopted in all cases. Resections were pursued up to functional boundaries defined intraoperatively by brain mapping techniques. We examined clinical, radiological, and intra-operative factors possibly affecting EOR and postoperative neurological, neuropsychological, and Quality of Life (QoL) outcomes. Results We finally enrolled 95 patients in the analysis. Mean EOR was 92.3%. A Gross Total Resection (GTR) was obtained in 70 cases (73.7%). Five patients reported permanent morbidity (aphasia in 3, 3.2%, and superior quadrantanopia in 2, 2.1%). Suboptimal EOR associated with poor seizures control postoperatively. Extensive intraoperative mapping (inclusive of cognitive, visual, and haptic functions) decreased long-term neurological, neuropsychological, and QoL morbidity and increased EOR. Tumor infiltration of deep perforators (vessels arising either medial to lenticulostriate arteries through the anterior perforated substance or from the anterior choroidal artery) associated with a higher chance of postoperative ischemia in consonant areas, with the persistence of new-onset motor deficits 1-month post-op, and with minor EOR. Ischemic insults in eloquent sites represented the leading factor for long-term neurological and neuropsychological morbidity. Conclusion In giant insular gliomas, the use of a transcortical approach with extensive brain mapping under awake anesthesia ensures broad insular exposure and extension of the surgical resection preserving patients’ functional integrity. The relation between tumor mass and deep perforators predicts perioperative ischemic insults, the most relevant risk factor for long-term and permanent postoperative morbidity.
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Affiliation(s)
- Marco Rossi
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Lorenzo Gay
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Marco Conti Nibali
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Tommaso Sciortino
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Federico Ambrogi
- Laboratory of Medical Statistics, Biometry, and Epidemiology "G.A. Maccararo," Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
| | - Antonella Leonetti
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Laboratorio Interdisciplinare di Tecnologie Avanzate (LITA), Milano, Italy
| | - Guglielmo Puglisi
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy.,Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Laboratorio Interdisciplinare di Tecnologie Avanzate (LITA), Milano, Italy
| | - Henrietta Howells
- Laboratory of Motor Control, Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Laboratorio Interdisciplinare di Tecnologie Avanzate (LITA), Milano, Italy
| | - Paola Zito
- Department of Anesthesia and Intensive Care, Humanitas Research Hospital, IRCCS, Milano, Italy
| | - Federico Villa
- Department of Anesthesia and Intensive Care, Humanitas Research Hospital, IRCCS, Milano, Italy
| | - Gjulio Ciroi
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Marco Riva
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
| | - Lorenzo Bello
- Neurosurgical Oncological Unit, Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milano, Italy
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18
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Huang Z, Lu C, Li G, Li Z, Sun S, Zhang Y, Hou Z, Xie J. Prediction of Lower Grade Insular Glioma Molecular Pathology Using Diffusion Tensor Imaging Metric-Based Histogram Parameters. Front Oncol 2021; 11:627202. [PMID: 33777772 PMCID: PMC7988075 DOI: 10.3389/fonc.2021.627202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/18/2021] [Indexed: 12/20/2022] Open
Abstract
Objectives To explore whether a simplified lesion delineation method and a set of diffusion tensor imaging (DTI) metric-based histogram parameters (mean, 25th percentile, 75th percentile, skewness, and kurtosis) are efficient at predicting the molecular pathology status (MGMT methylation, IDH mutation, TERT promoter mutation, and 1p19q codeletion) of lower grade insular gliomas (grades II and III). Methods 40 lower grade insular glioma patients in two medical centers underwent preoperative DTI scanning. For each patient, the entire abnormal area in their b-non (b0) image was defined as region of interest (ROI), and a set of histogram parameters were calculated for two DTI metrics, fractional anisotropy (FA) and mean diffusivity (MD). Then, we compared how these DTI metrics varied according to molecular pathology and glioma grade, with their predictive performance individually and jointly assessed using receiver operating characteristic curves. The reliability of the combined prediction was evaluated by the calibration curve and Hosmer and Lemeshow test. Results The mean, 25th percentile, and 75th percentile of FA were associated with glioma grade, while the mean, 25th percentile, 75th percentile, and skewness of both FA and MD predicted IDH mutation. The mean, 25th percentile, and 75th percentile of FA, and all MD histogram parameters significantly distinguished TERT promoter status. Similarly, all MD histogram parameters were associated with 1p19q status. However, none of the parameters analyzed for either metric successfully predicted MGMT methylation. The 25th percentile of FA yielded the highest prediction efficiency for glioma grade, IDH mutation, and TERT promoter mutation, while the 75th percentile of MD gave the best prediction of 1p19q codeletion. The combined prediction could enhance the discrimination of grading, IDH and TERT mutation, and also with a good fitness. Conclusions Overall, more invasive gliomas showed higher FA and lower MD values. The simplified ROI delineation method presented here based on the combination of appropriate histogram parameters yielded a more practical and efficient approach to predicting molecular pathology in lower grade insular gliomas. This approach could help clinicians to determine the extent of tumor resection required and reduce complications, enabling more precise treatment of insular gliomas in combination with radiotherapy and chemotherapy.
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Affiliation(s)
- Zhenxing Huang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases (China), Beijing, China
| | - Changyu Lu
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Gen Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases (China), Beijing, China
| | - Zhenye Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases (China), Beijing, China
| | - Shengjun Sun
- National Clinical Research Center for Neurological Diseases (China), Beijing, China.,Neuroimaging Center, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yazhuo Zhang
- National Clinical Research Center for Neurological Diseases (China), Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Zonggang Hou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases (China), Beijing, China
| | - Jian Xie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases (China), Beijing, China
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