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Deep Posterior Frontal GBM: Awake Mapping

July 08, 2014

Transcript

This video describes resection of a deep posterior frontal high-grade glioma using mapping strategies to maximize resection. This is a 38 year-old female with mild confusion. The location of the heterogeneously enhancing tumor within the deep portion of the dominant frontal lobe is evident. There's significant evidence of edema associated with this mass access to this tumor would require a corticonomy within the posterior aspect of the inferior frontal lobe and therefore an awake craniotomy deemed appropriate to accurately and safely position the location of the corticonomy for maximum tumor resection. Prevalent near incision was used. Frontal craniotomy as well as a temporal one was carried out. Dura was open there currently in fashion as subdural strip electrode was used for electrocorticography under weak conditions, the broadcast area or language expressive was mapped. You can see the most anterior extent of the functional cortex. Super stimulation mapping of this area did not reveal any interference with the speech. And therefore I felt a very posteriorly located incision would be safe to maximize tumor resection. So here's the Sylvian fissure, you can see the age of the mark for the speech area. Cortical incision was used for the exposure of this tumor, ultimately dissection of the fissure and its sub peel evacuation would be necessary for maximum tumor removal. The initial corticonomy is extended deep to a level of the tumor using neuro navigation, essentially a cap of the brain over the tumor was removed, so that this large deep tumor can be adequately exposed. Then resected here's some appeal. The resection of the tumor facing the frontal surface of the Sylvian fissure. Bipolar forceps were used as scissors for disconnection of their normal white matter from the pre tumoral areas. Now we're reaching the most lateral surface of the tumor. I stay at the periphery of the tumor here. You can see some of the degenerated portions of the tumor. Here's the roof of the orbit significant portion of the lateral part of the tumor has been removed. You can see small residual mass more immediately. I continue to circumferential disconnect the border of the tumor that is quite different from the normal brain. I prefer vascularization and areas of necrosis are quite apparent. The forceps are used at a higher intensity level, so they can be effective, essentially, a scissors to disconnect the per tumoral areas from the normal brain. Now we're getting to the peel surfaces over the Sylvian fissure. The MC branches are apparent careful dissection under magnification is important so that all the feeding vessels to the tumor can be differentiated from the emphasized vessels. Continuous neurological examination is performed intraoperatively to make sure that the patient's speech remains intact. Again, dissection around the Sylvian fissure. The feeding vessels at the surface of the tumor are evident and this deep portion of the tumor can be delivered after its medial capsule is carefully dissected from the MC at branches, postoperative MRI demonstrated effective removal of the mass without any complicating features. Thank you.

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