Microsurgical resection of fronto-temporo-insular gliomas in the non-dominant hemisphere, under general anesthesia using adjunct intraoperative MRI and no cortical and subcortical mapping: a series of 20 consecutive patients

Abstract

Fronto-temporo-insular (FTI) gliomas continue to represent a surgical challenge despite numerous technical advances. Some authors advocate for surgery in awake condition even for non-dominant hemisphere FTI, due to risk of sociocognitive impairment. Here, we report outcomes in a series of patients operated using intraoperative magnetic resonance imaging (IoMRI) guided surgery under general anesthesia, using no cortical or subcortical mapping. We evaluated the extent of resection, functional and neuropsychological outcomes after IoMRI guided surgery under general anesthesia of FTI gliomas located in the non-dominant hemisphere. Twenty patients underwent FTI glioma resection using IoMRI in asleep condition. Seventeen tumors were de novo, three were recurrences. Tumor WHO grades were II:12, III:4, IV:4. Patients were evaluated before and after microsurgical resection, clinically, neuropsychologically (i.e., social cognition) and by volumetric MR measures (T1G+ for enhancing tumors, FLAIR for non-enhancing). Fourteen (70%) patients benefited from a second IoMRI. The median age was 33.5 years (range 24–56). Seizure was the inaugural symptom in 71% of patients. The median preoperative volume was 64.5 cm3 (min 9.9, max 211). Fourteen (70%) patients underwent two IoMRI. The final median EOR was 92% (range 69–100). The median postoperative residual tumor volume (RTV) was 4.3 cm3 (range 0–38.2). A vast majority of residual tumors were located in the posterior part of the insula. Early postoperative clinical events (during hospital stay) were three transient left hemiparesis (which lasted less than 48 h) and one prolonged left brachio-facial hemiparesis. Sixty percent of patients were free of any symptom at discharge. The median Karnofsky Performance Score was of 90 both at discharge and at 3 months. No significant neuropsychological impairment was reported, excepting empathy distinction in less than 40% of patients. After surgery, 45% of patients could go back to work. In our experience and using IoMRI as an adjunct, microsurgical resection of non-dominant FTI gliomas under general anesthesia is safe. Final median EOR was 92%, with a vast majority of residual tumors located in the posterior insular part. Patients experienced minor neurological and neuropsychological morbidity. Moreover, neuropsychological evaluation reported a high preservation of sociocognitive abilities. Solely empathy seemed to be impaired in some patients.

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

“…Importantly, the rate of RTW was significantly higher in patients who underwent awake procedure, namely 95.5% vs 81.5% in group 1 ( P = .016). In a previous experience that analyzed RTW after right insular glioma surgery in patients operated on under general anesthesia using intraoperative MRI but without mapping, the rate of RTW was only 45%, 6 whereas the rate was 88.8% in another experience which used mapping techniques 19 in agreement with the present series.…”

“…17,18 Moreover, the rate of return to work (RTW) has exceptionally been assessed. 6,19 Finally, most of series mixed insular high-grade and low-grade gliomas, involving both hemispheres, with no distinct analysis between asleep and awake craniotomies. 10,[13][14][15][20][21][22] Here, the goal was to investigate functional outcomes after resecting specifically right insular/paralimbic low-grade glioma (LGG), without vs with awake mapping.…”

“…17,18 Moreover, the rate of return to work (RTW) has exceptionally been assessed. 6,19 Finally, most of series mixed insular high-grade and low-grade gliomas, involving both hemispheres, with no distinct analysis between asleep and awake craniotomies. 10,13-15,20-22…”

Influences on cognitive outcomes in adult patients with gliomas: A systematic review

“…Second surgery for recurrent HGG and LGG has been shown to be possible without significant cognitive damage in the months after surgery ( 109 ). Other studies have found a mixed picture of some patients experiencing cognitive improvement and others in the same study who experience cognitive decline or no change ( 39 , 58 , 60 , 76 , 110 – 113 ), or improvements in some cognitive domains and deterioration ( 2 ) or no change ( 46 ) in others; such a pattern could indicate ‘noise’ within the cognitive data. The cognitive domain being tested is important, as shown by one study where a decline in most cognitive domains was observed 5 days after surgery compared to pre-operatively, but only memory remained impaired 1 month after surgery ( 91 ).…”

Incidence of ischemic complications and technical nuances of arteries preservation for insular gliomas resection

“…Ischemic complications of insular glioma resection with a transcortical approach are commonly detected on postoperative MRI, with incidence ranging from 1.4% to 75.4%, and are a significant source of neurological morbidity (12,21,(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37). The primary series of procedures for insular glioma resection using the transcortical approach are presented in Table 5.…”