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Diffuse Dominant Insular Glioma

November 06, 2014


Diffused Dominant Insular Gliomas can be quite challenging to remove effectively. This is a 26 year-old female with intractable motor speech seizures. These seizures were quite frequent interfering with her ability to communicate. She underwent an MRI evaluation, which revealed the relatively diffused nature of this glioma involving the insula and part of the frontal lobe, as well as the temporal lobe. DTI demonstrated preservation of some of the fibers. Further imaging, including functional MRI, localized the location of motor speech as expected to the posterior inferior frontal lobe. Here's another view of the MRI. Again, the relatively non-defined margins of the tumor involving the insula and the posterior, inferior frontal lobe. This patient previously underwent a biopsy in an outside institution. Grade three, glioma astrocytoma was noted. We felt in an awake craniotomy is appropriate to maximize removal of this tumor. Both for goals of seizure control and improved oncological outcome. Standard left pterional craniotomy was performed. The dura was incised, generous exposure of the frontal and temporal lobes allowed mapping of the function, including the face area, motor speech and language so that both the transsylvian and transopercular corridors can be used for removal of this tumor. Here's the microsurgical portion of the operation. The Sylvian fissure was dissected, thin slough is already protruding through the Sylvian cisterns. The frontal opercular was dissected away from the surface of the insula. So the transsylvian trajectory can be initially exploited for removal of the tumor. However, the dissection of the insula from the superior temporal gyrus and more specifically from its medial peel surface is much easier since the MCA branches create a more generous cistern in this area. So the MCA branches were carefully dissected followed to the level of the M1, so that the superior and inferior preinsular sulci are available for surgical orientation. Here's the inferior preinsular sulcus, again defined the inferior border of the tumor. Neuronavigation also guides resection. Next, I used the cortical windowing technique working between the M2 branches to remove the tumor. Here is an M2 branch that's mobilized out of the way. Tumor was relatively suckable in this patient therefore it could be effectively removed through the transsylvian approach while undermining the frontal and temporal opercula. Here's the MCA branch within the right of our resection cavity, good resection was achieved. Transopercular approach was not necessary in this patient. Aggressive coagulation of the lateral lenticulostriate arteries was avoided. Here, you can see relatively clean margins and the working corridors between the M2 branches toward the medial portion of the insula. We're very satisfied with the extent of the operation. Obviously the portion of the tumor affecting the anterior aspect of the temporal and frontal lobes was also removed. Here, you can see again the skeletonization of the MCA. Post-operative MRI in this patient demonstrated reasonable removal of the tumor within the insula. However, there was small amount of residual tumor close to the area of the striatum and corona radiata superiorly, which we felt was difficult to remove without associated morbidity. Thank you.

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