Left occipital high-grade glioma

Introduction

An uncommon location for gliomas is the occipital lobe, in which the incidence ranges from 5% to 10% in several series. Patients with occipital lobe gliomas typically present with seizures but can have more subtle deficits in visual fields and neurocognitive function, including attention, proprioception, reading, and writing. ^, Moreover, dominant hemisphere lesions can be in close juxtaposition to language-associated white matter tracts, in which surgery can be associated with significant morbidity. ^, In this chapter, we present a case of a dominant hemisphere occipital high-grade glioma.

Example case

Chief complaint: right-sided vision loss and difficulty speaking

History of present illness

A 73-year-old, right-handed woman with a history of hypertension, hypercholesterolemia, and asthma presented with progressive right-sided vision loss and difficulty speaking. She was seen by her primary care physician when she stated she noticed having a blind spot on the right side when she was at a four-way intersection. In addition, she complains of difficulty with word pronunciation ( Fig. 25.1 ).

Medications : Lisinopril, fluticasone, simvastatin.
Allergies : No known drug allergies.
Past medical and surgical history : Hypertension, hypercholesterolemia, asthma, right knee replacement.
Family history : No history of intracranial malignancies.
Social history : Retired teacher, no smoking, social alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Language: intact naming and repetition but with slight dysarthria; Cranial nerves II to XII intact except right homonymous hemianopsia; No drift, moves all extremities with full strength.
Imaging : Chest/abdomen/pelvis with no evidence of primary disease.

	Bob S. Carter, MD, PhD, Massachusetts General Hospital, Boston, MA, United States	Sunit Das, MD, PhD, St. Michael’s Hospital, University of Toronto, Toronto, Canada	Maciej S. Lesniak, MD, Northwestern University, Chicago, IL, United States	Jinsong Wu, MD, PhD, Fudan University, Huashan Hospital, Shanghai, China
Preoperative
Additional tests requested	None	Visual field testing	Visual field testing	Tasked-based BOLD DTI MRS PWI Neuropsychological assessment
Surgical approach selected	Left occipital craniotomy with 5-ALA	Left temporo-occipital craniotomy	Left occipital craniotomy	Left parietal needle biopsy (because of age)
Anatomic corridor	Occipital-parietal	Occipital–lingual gyrus	Occipital	Angular gyrus, IPL
Goal of surgery	Diagnosis, debulking	Resection of contrast-enhancing portion	Resection of contrast-enhancing portion	Diagnosis
Perioperative
Positioning	Left lateral	Left lateral	Left park bench	Prone with 30-degree left rotation
Surgical equipment	Surgical navigation Surgical microscope with 5-ALA Ultrasonic aspirator	Surgical navigation Ultrasound Surgical microscope Ultrasonic aspirator	Surgical navigation Surgical microscope	Surgical navigation Needle biopsy kit
Medications	5-ALA Mannitol, furosemide Antiepileptics	Steroids	Mannitol Steroids	Steroids Antiepileptics
Anatomic considerations	Posterior corpus callosum	Visual pathways, corpus callosum, ventricle	Motor and visual cortex, visual fields	Angular gyrus, STG/MTG, optic radiations, IFOF, splenium, major forceps of corpus callosum, precuneus, cuneus, parieto-occipital sulcus
Complications feared with approach chosen	Speech deficits	Visual deficit	Visual and motor deficit	Hemorrhage
Intraoperative
Anesthesia	General	General	General	General
Skin incision	U-shaped	Horseshoe	Linear	Linear
Bone opening	Left parieto-occipital	Left temporo-occipital	Left occipital	Left parietal (burr hole)
Brain exposure	Left parieto-occipital	Left temporo-occipital	Left occipital	Angular gyrus
Method of resection	Craniotomy based on navigation, dural opening, trans parieto-occipital based on navigation using shortest distance, internal debulking, resect residual with 5-ALA, anticipate residual anteriorly near corpus callosum	Craniotomy based on navigation, flap designed based on axial planes, ultrasound to visualize most superficial portion of tumor to cortical surface, dural opening, corticectomy based on ultrasound, surgical microscope to dissect through white matter, internal debulking and working to the edges using ultrasound and microscope, dural tack up sutures	Craniotomy based on navigation, determine shortest distance based on navigation, internal debulking under microscopic visualization, minimize retraction, resection of enhancing portion	Trajectory based on navigation, burr hole, dural opening over angular gyrus, targeting three sites within lesion, four samples from each target point
Complication avoidance	Internal debulking, 5-ALA, anticipate anterior residual	Internal debulking	Internal debulking	Angular gyrus starting point, needle biopsy
Postoperative
Admission	ICU	ICU	ICU	ICU
Postoperative complications feared	Expect visual deficit, speech deficit	Visual deficit, CSF leak	Visual deficit, seizure	Hemorrhage
Follow-up testing	MRI within 48 hours after surgery	MRI within 48 hours after surgery	CT within 12 hours after surgery MRI within 48 hours after surgery	CT head immediately after surgery
Follow-up visits	7–10 days after surgery	1 month after surgery	14 days after surgery	1 month after surgery
Adjuvant therapies recommended
IDH status	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide + TTF Wild type–radiation/temozolomide + TTF	Mutant–radiation/ temozolomide Wild type–radiation/temozolomide
MGMT status	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide + TTF Unmethylated–radiation/temozolomide + TTF	Methylated–temozolomide Unmethylated–radiation/ temozolomide