Transcortical approach for insular gliomas: a series of 253 patients

Li, Zhenye; Li, Gen; Liu, Zhenxing; Pan, Yuesong; Hou, Zhiyong; Wu, Liang; Huang, Zhenxing; Zhang, Yazhou; Xie, Jian

doi:10.1007/s11060-020-03390-2

Cited by 23 publications

(50 citation statements)

References 25 publications

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“…This space is very narrow in nontumoral hemispheres and is approximately 3 mm, whereas in tumoral hemispheres, it extends up to 21 mm [27]. Identi cation of the UF/IFOF complex is important from a surgical point of view in terms of the risk of injury to the lenticulostriate arteries (LSAs) related to anterior perforating substances [40,23,17,26]. As these small branches provide vascular supply to the basal ganglia and internal capsule, it is reasonable to leave a small amount of the tumor medially to the UF/IFOF complex at the level of the temporal stem to avoid injuring them [6].…”

Section: Discussionmentioning

confidence: 99%

Anatomical aspects of the insula, opercula and peri-insular white matter for a transcortical approach to insular glioma resection

Dziedzic

Bala²,

Marchel³

2021

Preprint

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Introduction: The insula is a lobe located deep in each hemisphere of the brain and is surrounded by eloquent cortical, white matter and basal ganglia structures. The aim of this study was to provide an anatomical description of the insula and white matter tracts related to surgical treatment of gliomas through a transcortical approach. The study also discusses surgical implications in terms of intraoperative brain mapping. Methods Five adult brains were prepared according to the Klingler technique. Cortical anatomy was evaluated with the naked eye, whereas white matter dissection was performed with the use of a microscope. Results The widest exposure of the insular surface was noted through the temporal operculum, mainly in Zones III and IV according to the Berger-Sanai classification. By going through the pars triangularis in all cases, the anterior insular point and most of Zone I were exposed. The narrowest and deepest operating field was observed by going through the parietal operculum. This method provided a suitable approach to Zone II, where the corticospinal tract is not covered by the basal ganglia and is exposed just under the superior limiting sulcus. At the subcortical level, the identification of the inferior frontoocipital fasciculus at the level of the limen insulae is critical in terms of preserving the lenticulostriate arteries. Conclusion Detailed knowledge of the anatomy of the insula and subcortical white matter that is exposed through each operculum is essential in preoperative planning as well as in the intraoperative decision-making process in terms of intraoperative brain mapping.

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Section: Discussionmentioning

confidence: 99%

Anatomical aspects of the insula, opercula and peri-insular white matter for a transcortical approach to insular glioma resection

Dziedzic

Bala²,

Marchel³

2021

Preprint

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“…A transcortical approach was used for all insular tumors under general anesthesia, as published before [13]. Regarding the preservation of LLSAs and main M2 branches of MCA, in our experience, there are three key points: First, if the initial segment of LLSAs were encased by the tumor, a small cone-like tumor tissue at the initial segment of LLSAs would be left not only for the preservation proximal branches of LLSAs but also for the support LLSAs to avoid distortion resulting in ischemia (Fig.…”

Section: Microsurgical Technique and Key Pointsmentioning

confidence: 99%

“…Initiatively hemostasis rather than passive hemostasis was used to prevent the damage to the main branches of M2 [19]. After the tumor had been resected, the skeletonized main branches of M2 were preserved and suspended in the operative cavity [13]. All the surgical procedures were done with continuously IONM.…”

Section: Microsurgical Technique and Key Pointsmentioning

confidence: 99%

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

Hou

Huang

et al. 2021

Preprint

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Insular gliomas remain surgically challenge due to their complex anatomical position and microvascular supply. The incidence of ischemic complications is a risk that should not be ignored. The goal of this study was to analyze the incidence of ischemia and its risk factors, and also describe a single surgeon's arteries protection experience of insular gliomas resection. The authors studied 75 consecutive cases of insular gliomas that underwent transcortical tumor resection in their division. Analysis included pre- and postoperative demographic, clinical, radiological including diffusion weighted imaging (DWI), as well as intraoperative neurophysiology data, and functional outcomes. Strategies such as “Residual Triangle”, “Basal Ganglia Reconstruction” and “Sculpting Technique” were used to protect lateral lenticulostriate arteries and main branches of M2 for maximal tumor resection according to the different classification of Berger-Sinai. Postoperative diffusion-weighted imaging showed acute ischemia in 44 patients, only 9 of whom developed new motor deficits. Flat inner edge (OR 0.144 95% CI 0.024, 0.876), and motor evoked potentials (MEPs) (<50%) (OR 18.182, 95% CI 3.311, 100.00) were determined to have significant associations with postoperative Critical Ischemia, which located in the posterior limb of the internal capsule or corona radiata. For insular gliomas resection, the protection of main branches of MCA is important. Insular gliomas resection might be with high incidence of ischemia uncovered by DWI which not always result in neurological deficits. Their own strategies maybe the feasible technical nuances allow the surgeon to achieve a thorough and safe resection. Motor evoked potentials is essential for its resection.

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“…Attempting to predict molecular alterations using MRI scanning has been widely accepted as a rational approach to glioma treatment, and as such it has become an inevitable part of the treatment process. Due to the abundant nerve fiber projections present in insular gliomas (9), diffusion tensor imaging (DTI)-based tractography is valuable during surgical planning and has been found to preserve function (10); therefore, it has been applied preoperatively in many centers (11)(12)(13). Two DTI metrics, fractional anisotropy (FA) and mean diffusivity (MD), have been widely used in the prediction of glioma characteristics (14)(15)(16), and have been reported to be sufficient for predicting molecular alterations relative to the use of more advanced diffusion imaging methods (17).…”

Section: Introductionmentioning

confidence: 99%

Prediction of Lower Grade Insular Glioma Molecular Pathology Using Diffusion Tensor Imaging Metric-Based Histogram Parameters

Huang

et al. 2021

Front. Oncol.

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ObjectivesTo explore whether a simplified lesion delineation method and a set of diffusion tensor imaging (DTI) metric-based histogram parameters (mean, 25th percentile, 75th percentile, skewness, and kurtosis) are efficient at predicting the molecular pathology status (MGMT methylation, IDH mutation, TERT promoter mutation, and 1p19q codeletion) of lower grade insular gliomas (grades II and III).Methods40 lower grade insular glioma patients in two medical centers underwent preoperative DTI scanning. For each patient, the entire abnormal area in their b-non (b0) image was defined as region of interest (ROI), and a set of histogram parameters were calculated for two DTI metrics, fractional anisotropy (FA) and mean diffusivity (MD). Then, we compared how these DTI metrics varied according to molecular pathology and glioma grade, with their predictive performance individually and jointly assessed using receiver operating characteristic curves. The reliability of the combined prediction was evaluated by the calibration curve and Hosmer and Lemeshow test.ResultsThe mean, 25th percentile, and 75th percentile of FA were associated with glioma grade, while the mean, 25th percentile, 75th percentile, and skewness of both FA and MD predicted IDH mutation. The mean, 25th percentile, and 75th percentile of FA, and all MD histogram parameters significantly distinguished TERT promoter status. Similarly, all MD histogram parameters were associated with 1p19q status. However, none of the parameters analyzed for either metric successfully predicted MGMT methylation. The 25th percentile of FA yielded the highest prediction efficiency for glioma grade, IDH mutation, and TERT promoter mutation, while the 75th percentile of MD gave the best prediction of 1p19q codeletion. The combined prediction could enhance the discrimination of grading, IDH and TERT mutation, and also with a good fitness.ConclusionsOverall, more invasive gliomas showed higher FA and lower MD values. The simplified ROI delineation method presented here based on the combination of appropriate histogram parameters yielded a more practical and efficient approach to predicting molecular pathology in lower grade insular gliomas. This approach could help clinicians to determine the extent of tumor resection required and reduce complications, enabling more precise treatment of insular gliomas in combination with radiotherapy and chemotherapy.

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Transcortical approach for insular gliomas: a series of 253 patients

Cited by 23 publications

References 25 publications

Anatomical aspects of the insula, opercula and peri-insular white matter for a transcortical approach to insular glioma resection

Anatomical aspects of the insula, opercula and peri-insular white matter for a transcortical approach to insular glioma resection

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

Prediction of Lower Grade Insular Glioma Molecular Pathology Using Diffusion Tensor Imaging Metric-Based Histogram Parameters

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