Butterfly high-grade glioma

Introduction

Patients with high-grade gliomas are known to have poor survival. Among these patients, it is argued that butterfly lesions that cross the corpus callosum and involve both cerebral hemispheres have the worst prognoses. ^, Because of this presumed poor prognosis of butterfly lesions, patients with these lesions typically only undergo biopsy followed by adjuvant therapy. ^, However, more recent studies show that these patients may also benefit from extensive resection similar to their counterparts that only involve one hemisphere. ^, In this chapter, we present a case of a butterfly high-grade glioma.

Example case

Chief complaint: lethargy

History of present illness

A 29-year-old, right-handed woman with no significant past medical history who was transferred after a needle biopsy revealing glioblastoma for increasing lethargy. She initially presented with worsening headaches, and imaging revealed a large brain tumor. She underwent a right frontal needle biopsy consistent with glioblastoma 3 days prior. In the interim, she developed progressive lethargy and was transferred for further evaluation and management ( Fig. 29.1 ).

Medications : Dexamethasone 4 mg every 6 hours, levetiracetam.
Allergies : No known drug allergies.
Past medical and surgical history : Right frontal needle biopsy 3 days prior.
Family history : No history of intracranial malignancies.
Social history : Graduate student. No smoking, social alcohol.
Physical examination : Sleepy, arouses to voice, oriented to person, place, and time; Language : intact naming and repetition; Cranial nerves II to XII intact; Unable to participate with drift, moves all extremities with good strength.

	Chetan Bettegowda, MD, PhD, Johns Hopkins University, Baltimore, MD, United States	Zvi Ram, MD, Tel Aviv Medical Center, Tel Aviv, Israel	Michael E. Sughrue, MD, Prince of Wales Hospital, Sydney, Australia	Shota Tanaka, MD, PhD, The University of Tokyo, Tokyo, Japan
Preoperative
Additional tests requested	None	DTI Neuropsychological assessment	DTI fMRI	PET methionine Ophthalmologic examination
Surgical approach selected	Bifrontal craniotomy	Left frontal craniotomy with 5-ALA	Left frontal craniotomy	Right frontal craniotomy with 5-ALA
Anatomic corridor	Bifrontal	Left MFG	Left MFG	Right frontal
Goal of surgery	Debulking	Gross total resection of enhancing component	Gross total resection	Debulking
Perioperative
Positioning	Supine neutral	Supine neutral	Supine neutral	Supine neutral
Surgical equipment	Surgical navigation IOM (SSEP, EEG) Surgical microscope Ultrasound Ultrasonic aspirator	Surgical navigation Surgical microscope with 5-ALA Ultrasonic aspirator Brain stimulator IOM	Surgical navigation Surgical microscope	Surgical navigation IOM (MEP) Surgical microscope with 5-ALA Doppler
Medications	Mannitol Steroids Antiepileptics	Steroids	Mannitol Steroids	Mannitol Steroids Antiepileptics
Anatomic considerations	Frontal sinus, superior sagittal sinus, lateral ventricles, ACAs, internal capsule, basal ganglia, choroid vessels, fornices	ACA, lateral ventricles, CST	ACA, DMN/salience network, cingulum, caudate, contralateral cingulate gyrus	ACA
Complications feared with approach chosen	Vascular injury, injury to Sylvian vessels, forniceal injury	Motor deficits, intraventricular hemorrhage, ACA stroke	Preserving DMN/salience networks	Vascular injury to ACA
Intraoperative
Anesthesia	General	General	General	General
Skin incision	Bifrontal	Bifrontal	Bifrontal	Curved
Bone opening	Bilateral frontal	Left frontal	Left frontal	Right frontal
Brain exposure	Bilateral frontal	Left SFG/MFG	Left SFG/MFG/IFG	Right frontal
Method of resection	Bifrontal incision with pericranial graft, right frontal and separate left frontal craniotomies, start on right side, open dura around biopsy sight and enter tumor along biopsy tract and tumor debulking, open left frontal dura, enter left side and debulk tumor, leave intraventricular component, EVD placement	Bifrontal incision, left frontal craniotomy to midline, U-shaped dural opening based on midline, expose SFG, access tumor through the SFG, debulk using ultrasonic aspirator, chase tumor to contralateral side with removal of genu, attempt to avoid ventricular entry and spare bilateral ACAs, stimulate posterior to avoid CST injury	Left frontal craniotomy, expose MFG, access tumor through superior/medial surface and expose tumor lateral to cingulate, resect posterior and deep areas avoiding caudate head, resect between callosal sulcus and ventricle, enter ventricle and section septum pellucidum, identify right caudate head and resect tumor medial to it, stay superior to rostrum to avoid septal nuclei, EVD placement	Right frontal craniotomy, dural opening, expose right SFG/MFG, entry into tumor under microscopic visualization, resection with careful attention to ACAs, further resection into genu and opening of left frontal cystic/necrotic component, reconstruction of ventricular wall if entered
Complication avoidance	IOM, separate bifrontal craniotomies, follow previous surgical track, debulk tumor until reduction in mass effect, EVD	Expose SFG, stay within tumor, stimulate posterior aspect to avoid CST injury, avoid aggressive right-sided resection	Identify and avoid bilateral caudate heads, cingulate gyrus, callosal sulcus, EVD	Right frontal entry, IOM
Postoperative
Admission	ICU	ICU	ICU	ICU
Postoperative complications feared	Hydrocephalus, intraventricular hemorrhage, ACA injury, seizures, weakness, language deficit	ACA injury, intraventricular hemorrhage, CST injury, SMA syndrome	Hydrocephalus, vasospasm	Vasospasm, infarction
Follow-up testing	HCT immediately after surgery MRI within 24 hours after surgery Physical/occupational/speech therapy	CTA if motor deficit MRI within 48 hours after surgery	MRI within 24 hours after surgery	MRI within 48 hours after surgery
Follow-up visits	14 days after surgery	14 days after surgery	14 days after surgery 7 days after surgery for neurooncology	14–21 days after surgery
Adjuvant therapies recommended
IDH status	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide + TTF Wild type–radiation + TTF	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide Wild type–radiation/temozolomide
MGMT status	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide + TTF Unmethylated–radiation + TTF	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide