Left perirolandic high-grade glioma

Introduction

In general, the most critical eloquent locations are the language and motor areas. In a meta-analysis on intraoperative stimulation brain mapping for glioma surgery, De Witt Hammer and colleagues found that late severe neurologic deficits were seen in 8.2% of patients without brain mapping and in 3.4% of patients with brain mapping. In addition, the percent of radiographically confirmed gross total resection was 58% in cases without brain mapping as compared with 75% with brain mapping, in which eloquent involvement was seen in 95.8% of nonbrain mapping cases, and 99.9% of brain mapping cases. In this chapter, we present a case that involves the left perirolandic region in close proximity to the corticospinal and superior longitudinal white matter tracts.

Example case

Chief complaint: right-sided weakness and double vision

History of present illness

A 53-year-old, right-handed man with a history of liver disease presented with progressive right-sided weakness and diplopia. Over the past 3 weeks, he developed progressive right arm and leg weakness to the point in which he had difficulty with coordination. He was seen by his primary care physician who ordered brain imaging that revealed a brain lesion ( Fig. 18.1 ). He was referred for evaluation and management.

Medications : None.
Allergies : No known drug allergies.
Past medical and surgical history : Liver disease.
Family history : No history of intracranial malignancies.
Social history : Engineer, no smoking or alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Cranial nerves II to XII intact; Right drift, right upper extremity 4/5, right lower extremity 4+/5.
Imaging : Chest/abdomen/pelvis computed tomography negative for primary malignancy.

	Linda M. Liau, MD, PhD, University of California-Los Angeles, Los Angeles, CA, United States	Ian F. Parney, MD, PhD, Mayo Clinic, Rochester, MN, United States	Zvi Ram, MD, Tel Aviv Medical Center, Tel Aviv, Israel	Pierre A. Robe, MD, PhD, University Medical Center of Utrecht, The Netherlands
Preoperative
Additional tests requested	DTI fMRI Neuropsychological assessment Possible Wada (sodium amytal) test	DWI ESR/CRP	Neuropsychological assessment	DWI Surgery if biopsy confirms glioma
Surgical approach selected	Left fronto-parietal craniotomy with awake language and motor mapping	Left parietal stereotactic needle biopsy	Left frontal stereotactic needle biopsy	Left awake parietal craniotomy with cortical and subcortical mapping with 5-ALA
Anatomic corridor	Left fronto-parietal transsulcal based on DTI and mapping	Left superior parietal lobule	Left anterior frontal	Left parietal
Goal of surgery	Extensive resection of contrast-enhancing portion	Diagnosis	Diagnosis	Extensive resection and preservation of neurologic function
Perioperative
Positioning	Left lateral	Left lateral	Supine neutral	Left park bench
Surgical equipment	IOM (MEP, SSEP, ECoG), Surgical navigation Brain stimulator Surgical microscope	Surgical navigation Biopsy kit	Surgical navigation Biopsy kit	Surgical navigation Ultrasound Neuropsychological testing Surgical microscope 5-ALA
Medications	Mannitol Steroids Antiepileptics	Steroids	Steroids	Steroids Mannitol
Anatomic considerations	Primary motor and sensory cortex, CST	Primary motor and sensory cortex, CST	Motor cortex	Motor cortex, language pathways
Complications feared with approach chosen	Motor deficit	Motor deficit, hemisensory loss	Motor deficit	Motor, cognitive, proprioception, and speech deficits
Intraoperative
Anesthesia	Awake-asleep-awake	General	General	Awake
Skin incision	Inverted U	Linear	Linear	Linear
Bone opening	Left frontal-parietal	Left parietal	Left frontal burr hole	Left parietal
Brain exposure	Left frontal-parietal	Left superior parietal	Kocher point (SFG)	Left parietal
Method of resection	Left frontal-parietal bone flap, U-shaped dural opening based on sagittal sinus protecting draining veins, phase reversal to identify central sulcus, if unclear perform cortical mapping, open sulcus closest to tumor under microscopic visualization, resect tumor circumferentially if plane exists and guided by DTI, debulk inside-out if no plane or in close proximity to eloquent white matter tracts on DTI, watertight dural closure, tack up sutures	Left parietal incision, burr hole, open dura, insert needle under navigation guidance, four circumferential core biopsies, leave introducer in place while awaiting pathology review, 5 mm deeper biopsies if nondiagnostic, remove needle and introducer	Left frontal incision, burr hole, navigation-guided needle biopsy, await intraoperative path review prior to closure	Titrate sedation with intravenous anesthetics, scalp field block with local anesthetics, left parietal bone flap based on navigation, ultrasound to delineate tumor margins, open dura, cortical stimulation for positive language and motor sites with neuropsychologists, tumor resection with 5-ALA fluorescence, debulk tumor with ultrasonic aspirator, repetitive cortical and subcortical stimulation, ultrasound to evaluate extent of resection and hematoma
Complication avoidance	Phase reversal, cortical mapping, resection strategy based on planes	Needle biopsy through superior parietal lobule	Needle biopsy anterior to motor cortex	Cortical and subcortical stimulation, ultrasound
Postoperative
Admission	ICU	ICU	ICU	Floor
Postoperative complications feared	Right motor weakness or sensory deficit	Hemorrhage	Hemorrhage, motor deficit	Motor, cognitive, proprioception, and speech deficits
Follow-up testing	MRI brain with DTI within 24 hours after surgery	CT within 24 hours after surgery	Immediate postoperative head CT MRI within 48 hours after surgery	MRI within 72 hours after surgery
Follow-up visits	2 weeks after surgery	3 months after surgery 7 days after surgery with radiation and neurooncology	On obtaining pathology	As needed
Adjuvant therapies recommended
IDH status	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	If GBM, surgical resection through superior parietal lobule Mutant–radiation/temozolomide +/– TTF Wild type– radiation/temozolomide +/– TTF	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant: radiation/temozolomide Wild type: radiation/temozolomide
MGMT status	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	If GBM, surgical resection through superior parietal lobule Methylated–radiation/temozolomide +/– TTF Unmethylated–radiation/temozolomide +/– TTF	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated: radiation/temozolomide Unmethylated: radiation/temozolomide