Recurrent Insular Glioma: Fluorescence

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This video describes, intraoperative events for resection of a Recurrent Insular Glioma. This is a 42 year-old male, who presented with a history of subtotal removal of his left insular low-grade tumor. He did not undergo Radiotherapy. Surveillance imaging two years later, demonstrated nodular enhancement of the tumor in the area of the Insula. He subsequently went to the reopening of his Craniotomy and resection of the enhancing nodule. Important consideration during this surgery is preservation of the M2 branches and obviously, identification of the Lateral Lenticulostriate Arteries that should be preserved to avoid any Postoperative Hemiparesis. Let's go ahead and review the Intraoperative events in this case. The linear part of the incision was reopened. The Dura was incised in a cruciate fashion. You can see the small amount of brain over the insula, that is gliotic. This part of the region is being removed. The procedure was conducted with the patient asleep. Portion of the Superior Temporal Gyrus, over the insula was removed. Here is one of the M2 branches, that is being mobilized. So, I can create working windows between the M2 branches, to remove the tumor within the insula. Fluorescein fluorescence was also employed to identify the nodule and assure cold store removal of enhancing portion of the tumor. Here's the use of Fluorescein fluorescence under YELLOW 560. You can see the nodule is apparent over the lateral aspect of the insula. This nodule was biopsied. The frozen section was consistent with high-grade Glioma. You can see under white light, there's no significant differentiation between the tumor and normal white matter. Therefore, I continue to use Fluorescein fluorescence to remove the enhancing part of the tumor within the insula. I knew cold store removal of the tumor is not achievable safely. Here, using the Fluorescein fluorescence, the enhancing part of the tumor is quite apparent. Again, I'm working between the M2 branches, mobilizing some of them, if necessary. Extending my Chortecadmy within the insula, so, the margins of the enhancing nodule are exposed. Here is residual tumor, more anteriorly and superiorly. Obviously, the Lenticulostriate Arteries should be carefully protected. You can see one of the Lenticulostriate Arteries. I continue to focus my attention along the periphery of the resection cavity rather than more medially. Final touches. Here's one of the M2 branches. Small residual tumor, more anteriorly and superiorly. Cavity appears relatively clean, otherwise. Some residual tumor, again. More superiorly, continue my resection. Inferiorly, I run into the previous resection cavity. No obvious enhancing nodule is apparent. I'm relatively satisfied. Let's go ahead and look at the resection cavity using white light. Navigation confirms cold store resection of the enhancing portion of the tumor. But before we do that, further investigation reveals residual tumor. This part is also being evacuated. Here, You can see under white light, one of the lateral Lenticulostriate Arteries through the insula and other one here. Obviously, these vessels have to be carefully protected. I usually base these vessels with Papaverin Soaked Gelfoam to avoid any vasospasm within them. Obviously, these vessels define the absolute medial border of the resection. Aggressive coagulation is minimized. Gentle tapping, using a piece of cotton is the safest method for achieving hemostasis, without injury to these fine vessels. Another look of these very important perforating vessels. What a magnified view of the operative space! The M2 branch and the Postoperative MRI in this case, demonstrated removal of the enhancing part of the tumor without any complicating feature. And this patient recovered from his surgery, uneventfully. Thank you.

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