Central Lobule Glioma: Principles of Mapping to Maximize Safe Resection

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It is often difficult to know which gliomas infiltrating the central lobule are good candidates for resection. However, mapping and subtotal resection may be reasonable under certain circumstances. This is a 52 year-old male who presented with intractable right-sided motor seizures and due to intractability of his seizures, resection of the mass even subtotal was deemed appropriate. MRI demonstrates the location of this non-enhancing tumor and its infiltration of the motor cortex. Here is the central sulcus precentral gyrus in infiltration of the motor cortex. Cranial T2 MRI demonstrates the infiltration of the white matter, and enhanced axial MRI demonstrates lack of enhancement of the tumor and a sagittal FLAIR image demonstrates the location of the marginal sulcus, the central labial, the precentral gyrus, and also infiltration of the motor cortex. Due to significant association of function of cortex with the tumor, an awake craniotomy was deemed the most reliable. The location of the skull clamp is evident. I increased the pressure on the pins to 80 pounds for an awake patient to avoid any displacement of the head during mapping. Here you can see the four circles demonstrating the 80 pounds. The scalp incision exposes the motor cortex located posterior to the tumor. Here's mapping of the margins of the tumor using MRI intraoperative navigation. Stimulation mapping was used to map the cortices corresponding to the hand, arm, and the face areas. Areas of the tumor were also heavily stimulated. Minor seizures were encountered. Here's the hand area for mapping, the arm area during mapping and followed by the face area. The cortices corresponding to these areas were tagged, here's the face area, the hand area infiltrated by the tumor, and also the arm area. This part of the tumor was removed however, during the removal of the tumor we encountered two continuous motor seizures. Ice cold saline was used to bathe the cortex and halt the seizures. You can see the evidence of motor activity transmitted to the head. In the right upper extremity was affected, ice cold saline was used to calm down the cortex and eventually halt the seizure activity. After the seizure activity was stopped, I continued removal of the tumor as much as possible. Again, the functional cortices were respected, subcortical mapping was used. You can see the arm activity in a moment related to the subcortical stimulation. I continue to clean out the margins of the tumor as much as possible using subcortical mapping in this area. Here, you can see the arm movement related to subcortical mapping therefore further resection closer to the motor cortex was avoided. Neuronavigation confirmed the boundaries of resection. Here's the final result of resection, and postoperative MRI demonstrated reasonable removal of the mass. This patient did have some mild deficit, mild right upper extremity weakness after surgery that somewhat improved. However, he gained significant control over his motor seizures. Thank you.

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