Awake Mapping With Transopercular Approach in Right Insular–Centered Low-Grade Gliomas Improves Neurological Outcomes and Return to Work

Abstract

BACKGROUND:Asleep vs awake surgery for right insula–centered low-grade glioma (LGG) is still debated.OBJECTIVE:To compare neurological outcomes and return to work after resection for right insular/paralimbic LGG performed without vs with awake mapping.METHODS:A personal surgical experience of right insula–centered LGG was analyzed, by comparing 2 consecutive periods. In the first period (group 1), patients underwent asleep surgery with motor mapping. In the second period (group 2), patients underwent intraoperative awake mapping of movement and cognitive functions.RESULTS:This consecutive series included 143 LGGs: 41 in group 1 (1999-2009) and 102 in group 2 (2009-2020). There were no significant difference concerning preoperative clinicoradiological characteristics and histopathology results between both groups. Intraoperative motor mapping was positive in all cases in group 1. In group 2, beyond motor mapping, somatosensory, visuospatial, language, and/or cognitive functions were identified during cortical–subcortical stimulation. Postoperatively, 3 patients experienced a long-lasting deterioration with 2 hemiparesis due to deep stroke (1.3%) and 1 severe depressive syndrome, all of them in group 1 vs none in group 2 (P = .022). The rate of RTW was 81.5% in group 1 vs 95.5% in group 2 (P = .016). The tumor volume and extent of resection did not significantly differ across both groups.CONCLUSION:This is the first study comparing asleep vs awake surgery for right insula–centered LGG. Despite similar extent of resection, functional outcomes were significantly better in awake patients by avoiding permanent neurological impairment and by increasing RTW. These results support the mapping of higher-order functions during awake procedure.

Laser interstitial thermal therapy for the treatment of insular lesions: A systematic review

“…The surgical resection of insular lesions is a challenge and is associated with a significant functional deficit ( 39 ). Two common open surgical options for insular lesions are the trans-sylvian and transcortical approaches with awake brain mapping ( 40 – 42 ). A meta-analysis of eighth studies evaluating 227 patients with insular gliomas showed that permanent neurological deficit was lower in cases with awake mapping (3.5 vs. 15.7%, p = 0.001).…”

Constant Multi-Tasking With Time Constraint to Preserve Across-Network Dynamics Throughout Awake Surgery for Low-Grade Glioma: A Necessary Step to Enable Patients Resuming an Active Life

“…Concerning the postoperative outcomes of LGG patients who benefited from intrasurgical multi-tasking in clinical routine, beyond an increase of the overall survival thanks to an optimization of the extent of resection ( 1 , 2 , 7 ), and besides the fact that the risk of long-term severe permanent neurological deficit is currently less than 1% ( 3 , 4 , 58 ), recent series in which objective neuropsychological assessments have systematically been performed after surgical resection demonstrated that a preservation or even an improvement of cognitive scores was found in most patients and should be considered as a standard of care – in patients with preoperative symptoms as well as in patients with incidental discovery of LGG ( 4 , 59 ). Interestingly, sparing the interplay between networks during a first surgery opened the door to subsequent operation(s) owing to mechanisms of functional reshaping which occurred in the meantime ( 2 , 60 , 61 ), and resulted in the maximization of resection while maintaining neurocognition and therefore quality of life ( 62 ).…”

“…Interestingly, sparing the interplay between networks during a first surgery opened the door to subsequent operation(s) owing to mechanisms of functional reshaping which occurred in the meantime ( 2 , 60 , 61 ), and resulted in the maximization of resection while maintaining neurocognition and therefore quality of life ( 62 ). Above all, the use of multi-tasking with time constraint in awake patient is associated with a higher rate of employment resumption ( 31 ), between 94% to 97% in recent experiences ( 3 , 4 , 58 ).…”

A Personalized Longitudinal Strategy in Low-Grade Glioma Patients: Predicting Oncological and Neural Interindividual Variability and Its Changes over Years to Think One Step Ahead

“…should also be pre-planned before the operation, in order for the patient and his or her family to organize appropriately in advance (in particular, arranging to stop work for a few weeks). This patient-specific surgical approach has led to minimization of severe permanent deficits (less than 1% occurrence), preservation or even improvement of postoperative cognitive scores, with RTW in over 94% of LGG patients [ 4 , 90 , 91 , 144 ]. Notably, RTW is a critical endpoint which has been severely neglected in the literature, and must be evaluated more systematically in future studies [ 145 ].…”