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Cingulate Glioma

June 09, 2015


Let's review strategies for a section of Cingulate Gliomas. In this case, a 51 year old male who suffered from a single seizure. MRI evaluation revealed a tumor, a glioma, within the cingulum wrapping around the corpus callosum, feathering more posteriorly, you can see the minimal amount of enhancement associated with this tumor. This tumor was ultimately diagnosed as a grade III anaplastic oligoastrocytoma. The location of the vascular structures along the medial capsule of that tumor is also demonstrated on this coronal T2 image. My operative strategy in this case involve the use of a right-sided or contralateral interhemispheric transfalcine approach, to be able to reach the more lateral part of the tumor. If I reached this tumor via the ipsilateral interhemispheric corridor, the reach of the operative corridor toward the lateral pole of the tumor can be compromised. Let's go ahead and review the operative events. A lumbar drain was installed at the beginning of the procedure. Patient is in the supine position, with the head in the neutral supine position. Here's a superior sagittal sinus, that's been partly unroofed. Again, the right frontal lobe, tumor is in the left cingulum. Relatively generous craniotomy in the parasagittal area, specially the exposure is generous in its anterior posterior dimension. The dura is reflected toward the left side. To expand the interhemispheric operative corridor, I placed two sutures within the superior falx just below the superior sagittal sinus, so that these retention sutures can gently mobilize the superior sagittal sinus out of my operative corridor. Here's the more posterior suture. Brain is quite relaxed with the use of lumbar drain. Three sutures were used in this case, then to remiss, rail corridor was entered, all the adhesions were microdissected. without cutting the falx, you can see the cingulum on the left side, the pericallosal artery. Other branches of these vessels are evident on the ipsilateral side. The tumor infiltrated cingulum is generously exposed, and this is part of the cingulum affected by the tumor, The corpus callosum is not evident yet, here you can see the cross-court trajectory. The vessels were very carefully handled. The tumor affected cingulum appears discolored. The vessels were carefully isolated before tumor removal was attempted, so that these vessels can be identified early and kept out of harm's way. So I followed the contour of the cingulum and removed the tumor, startling anteriorly, identifying the vessels, and then moving posteriorly, continuing my resection as guided by Neuronavigation. Along the posterior aspect of my resection, that falx appeared to interfere with the extent of the exposure and therefore a portion of the falx was cut to expose the contralateral cingulum. Here you can see more the magnified view of the operative corridor for your orientation. Minimal amount of retraction was necessary in this case. One has to always look for the pedicles or vessels. The inferior sagittal sinus was coagulated and cut. Here's a more generous exposure of the posterior extent of glioma infiltrated cingulum, the intact right cingulum was protected at all costs to minimize the risk of postoperative neurological and neuropsychological deficits. can see additional piece of a falx was removed to create an operative window toward the contralateral side. Using navigation, the contralateral cingulum and the adjacent tumor infiltrated areas were evacuated. Redirecting my view more posteriorly to make sure the tumor is adequately removed in this area. To me is relatively soft, more suckable can be evacuated via bipolar forceps and the suction device. Again, the pedicles, arteries are continuously inspected and carefully protected. Aggressive bleeding does not warrant the indiscriminate use of the bipolar coagulation for placing the hidden vascular structures at risk, I'm along the most posterior aspect of my resection cavity, more superiorly I made sure there's no residual tumor underneath the overhanging edges of the cortices, all the blind operating spots were carefully inspected. Here's the final view of the resection cavity and the postoperative MRI revealed adequate resection of this tumor. And this patient made an extra recovery without any significant worsening of his preoperative neuropsychological deficits, Thank you.

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