Introduction
Gliomas are known to infiltrate cortical areas and white matter tracts. , In low-grade gliomas (LGGs), there can be interspersing tumor with nontumor tissue. Therefore when LGGs involve eloquent regions, surgical resection can result in significant neurologic morbidity. A common location for LGGs is the perirolandic region, where surgery is associated with risk of motor weakness and sensory loss that can be debilitating and significantly affect quality of life. Dominant versus nondominant perirolandic involvement can alter management. In this chapter, we present an LGG that is in close proximity and possibly involves the precentral gyrus in the dominant hemisphere.
Chief complaint: headaches
History of present illness
A 46-year-old, right-handed woman with a history of anxiety and depression with a known lesion is being followed with serial imaging. Her history dates back to 5 years prior when she complained of headaches and underwent imaging that revealed the left-sided brain tumor. It was followed with serial imaging, and the lesion had increased in size ( Fig. 4.1 ). She remains with headaches that are responsive to acetaminophen, and was referred for further evaluation and management.
Medications : Alprazolam, clonazepam.
Allergies : No known drug allergies.
Past medical and surgical history : Anxiety and depression.
Family history : No history of intracranial malignancies.
Social history : Homemaker. No smoking history or alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Cranial nerves II to XII intact; No drift, moves all extremities with full strength.
| Steven Brem, MD, University of Pennsylvania, Philadelphia, PA, United States | Jeffrey N. Bruce, MD, Columbia University, New York City, NY, United States | Ricardo Díez Valle, MD, PhD, Fundación Jimenez Díaz University Clinic, Madrid, Spain | Santiago Gil-Robles, MD, PhD, Universidad Europea de Madrid, Madrid, Spain | |
|---|---|---|---|---|
| Preoperative | ||||
| Additional tests requested | DTI fMRI Perfusion MRI MRS Neuropsychological assessment | DTI | DTI fMRI or MEG Neuropsychological assessment | |
| Surgical approach selected | Left fronto-parietal craniotomy | Left fronto-parietal craniotomy with awake motor mapping | Left fronto-parietal craniotomy with IOM and iMRI with asleep mapping | Left paracentral craniotomy with awake mapping |
| Anatomic corridor | Fronto-parietal lobe over tumor surface | Fronto-parietal lobe over tumor surface | Fronto-parietal lobe over tumor surface | Left paracentral/precuneus |
| Goal of surgery | Maximal safe resection (80%–95%) | Extensive resection with functional preservation | Diagnosis, reduction of tumor mass | Extensive resection with functional preservation |
| Perioperative | ||||
| Positioning | Supine neutral | Left supine with slight rotation | Prone vs. left lateral | Left supine 45-degree rotation |
| Surgical equipment | Surgical navigation IOM (SSEP) Brain stimulator Surgical microscope Ultrasonic aspirator | Surgical navigation IOM (ECoG) Brain stimulator Ultrasound Ultrasonic aspirator Surgical microscope | Surgical navigation IOM Brain stimulator Surgical microscope with 5-ALA iMRI | Brain stimulator Surgical navigation Ultrasonic aspirator Speech therapist |
| Medications | Steroids Antiepileptics | Steroids Antiepileptics | Steroids | Steroids Antiepileptics |
| Anatomic considerations | Motor cortex, CST | Motor cortex | Motor and sensory cortex, terminal branches of ACA, sagittal sinus | Primary motor cortex (especially lower limb), IPL (language, reading, calculation), sensory cortex, thalamocortical pathway, CST, SLF I and II |
| Complications feared with approach chosen | Motor deficit | Motor deficit | Sagittal sinus and/or ACA injury, motor or somatosensory deficits | Motor, language, reading, calculation, and sensory deficits |
| Intraoperative | ||||
| Anesthesia | General | Asleep-awake-asleep | General | Asleep-awake-asleep |
| Skin incision | Linear parasagittal | Linear coronal | Linear | Horseshoe |
| Bone opening | Left fronto-parietal | Left fronto-parietal | Left fronto-parietal | Left frontal-parietal |
| Brain exposure | Left fronto-parietal | Left fronto-parietal | Left fronto-parietal | Paracentral and SPL/IPL |
| Method of resection | Keyhole craniotomy (~3 cm) ipsilateral to sagittal sinus, curvilinear dural opening, phase reversal to identify rolandic fissure, stimulate cortex with brain stimulator from 3–20 mA or higher to identify and avoid motor cortex, cortical entry where negative stimulation sites, transsulcal if eloquent, maximal safe resection with goal 80%–95% | Monitored anesthesia care, craniotomy ipsilateral to sagittal sinus, U-shaped dural opening based on sagittal sinus, grid placed for cortical mapping, awaken patient to map for motor cortex, resection based on motor mapping, internal debulking, ultrasound to determine if residual present | Craniotomy centered over lesion ipsilateral to sagittal sinus, dura opened to midline, mapping with monopolar and strip electrode to monitor MEP, dissection of tumor border and internal debulking with bipolar and forceps, iMRI to assess completeness of resection and need for further resection | Left parietal craniotomy, dural anesthesia, patient awoken, detection of boundaries based on navigation, identify motor cortex with low threshold stimulation (1.5–3 mA) with limb contraction, cortical mapping for motor/somatosensory/cognitive and language function, subpial resection of the postcentral sulcus and interparietal sulcus, alternate resection and stimulation until functional boundaries reached (medial primary motor of lower limb/thalamocortical pathway/SLF laterally |
| Complication avoidance | Phase reversal, cortical stimulation, transsulcal entry if eloquent, goal resection 80%–95% | ECoG and cortical and subcortical brain mapping, ultrasound | Cortical and subcortical mapping, MEP, iMRI | Cortical and subcortical mapping of motor/somatosensory cortex, IPL, thalamocortical/CST/SLF I and II |
| Postoperative | ||||
| Admission | ICU | ICU | ICU | ICU |
| Postoperative complications feared | Motor deficit, aphasia, seizures | Motor deficit, seizures | Right lower extremity motor or sensory deficit | Transient ataxia, lower limb palsy, aphasia |
| Follow-up testing | MRI within 24 hours after surgery Next generation sequencing | MRI within 48 hours after surgery | MRI within 72 hours after surgery | MRI within 24 hours after surgery Neuropsychological assessment Physical/cognitive therapy |
| Follow-up visits | 1 month after surgery | 7 days after surgery | 7 days after surgery | 7–10 days after surgery |
| Adjuvant therapies recommended | ||||
| Diffuse astrocytoma (IDH mutant, retain 1p19q) | GTR–radiation +/– temozolomide STR–radiation +/– temozolomide | GTR–radiation/temozolomide STR–radiation/temozolomide | GTR–radiation/temozolomide STR–radiation/temozolomide | <4 mm/year growth rate–observation >4 mm/year growth rate–radiation/temozolomide |
| Oligodendroglioma (IDH mutant, 1p19q LOH) | Pending positive TERT status, GTR–PCV or temozolomide STR–PCV or temozolomide | GTR–observation STR–radiation/temozolomide because of preop growth | GTR–radiation/PCV STR–radiation/PCV | GTR–observation STR–<4 mm/year growth rate–observation; >4 mm/year growth rate–PCV |
| Anaplastic astrocytoma (IDH wildtype) | GTR–radiation/temozolomide STR–radiation/temozolomide | GTR–radiation/temozolomide STR–radiation/temozolomide | GTR–radiation/temozolomide STR–radiation/temozolomide | Homogenous AA–radiation/temozolomide AA foci removal–treatment as for diffuse astrocytoma |
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