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Posterior Paracentral Lobule Glioma: Awake Subcortical Mapping

October 28, 2019


This is another video describing aggressive resection of gliomas affecting the paracentral lobule. This is a young patient who presented with a seizure and was unfortunately diagnosed with a low grade glioma affecting the posterior aspect of the paracentral lobule. Here's the central sulcus. As you can see most likely the tumor is affecting the posterior sensory cortex and pushing it most likely anteriorly giving the impression that the motor cortex is also affected. Here's the functional MRI demonstrating that again the motor cortex has been pushed anteriorly and more laterally. And with cortical mapping allows aggressive resection of these tumors. Here's the patient in the pinion. A large horseshoe incision to allow mapping of the normal cortices. Here's another point here. Obviously the incision is well injected. I also insist upon injecting the base of the flap so that during its reflection, the patient is more comfortable and is not suffering from any painful stimuli. Here's the dural opening, here's the midline superior sagittal sinus. The dura is reflected medially. Here's the anterior aspect of our craniotomy, motor cortex is most likely located here. I'll go ahead and map the hand and the arm and the shoulder. Now those areas are mapped. Here is, again, the margins of the tumor based on neuronavigation. I'll go ahead and start resection closer to the motor cortex during the initial stages of the operation when the patient is more awake and cooperative. I continue efficiently to disconnect the tumor using neuronavigation, especially more posteriorly and medially. I leave some tumor anteriorly underneath the functional cortices so that those can be removed more patiently using subcortical mapping and frequent intraoperative neurological examinations. Here's the bulk of the tumor. Now our real job starts with undermining the functional cortex and removing the discolored tumor. Obviously this part of the tumor is very obvious, very discolored, appears easily removable via the suction device. Frequent neurological evaluations are performed during this stage to the operation, and as the potentially peritumoral areas are encountered, subcortical mapping is instituted. Patient exam remains stable. We've continued dissection. Again, this is grossly abnormal. Very rubberish, characteristic of oligodendrogliomas. Now we'll go ahead and start with subcortical mapping. Another layer of the tumor is removed using ultrasonic aspirator. This device is quite effective in removing tumors more accurately in layers, while avoiding undue traction on the normal structures. Here again the use of subcortical mapping, and again removing tumor in layers. Another round of subcortical mapping. This time we had some activation of motor function. So the resection in that area was halted. More accuracy resection laterally was pursued. Here's the final product. Patient remained neurologically intact. And here you can see the extent of resection. Obviously this is not a gross total resection, but more than 90% resection should provide the patient with significant survival advantage. And this patient has remained functionally active to the date, and has not had any significant recurrence and remains neurologically intact. Thank you.

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