Left temporal high-grade glioma

Introduction

A common location for high-grade gliomas is the temporal lobe. In most series, this number ranges from 15% to 25%. Patients with dominant-hemisphere temporal lobe gliomas most commonly present with seizures, but those that do not typically have subtle deficits in attention, object naming, and language as compared with right temporal lobe lesions. In this chapter, we present a case of a dominant- hemisphere temporal lobe high-grade glioma.

Example case

Chief complaint: confusion

History of present illness

A 44-year-old, right-handed man with a history of traumatic brain injury (TBI) with left-sided ventriculoperitoneal shunt (VPS) 20 years prior presented with confusion. He had sustained a TBI after a motor vehicle accident (MVA) and developed hydrocephalus requiring a left frontal VPS (nonprogrammable) 20 years prior. Over the past 3 weeks, his parents noted that he has become increasingly confused with the time of day and where he is. He denies any loss of consciousness, staring episodes, or arm/leg shaking. Imaging was done and revealed a brain lesion ( Fig. 23.1 ).

Medications : None.
Allergies : No known drug allergies.
Past medical and surgical history : Right VPS after MVA and TBI.
Family history : No history of intracranial malignancies.
Social history : Dependent on his parents for activities of daily living after MVA. No smoking or alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Language: intact naming and repetition; Cranial nerves II to XII intact; No drift, moves all extremities with full strength.
Imaging : Chest/abdomen/pelvis with no evidence of primary disease.

	Hossam El-Husseiny, MBBS, Ain Shams University, Cairo, Egypt	Gordon Li, MD, Stanford University, Palo Alto, CA, United States	Walter Stummer, MD, PhD, University of Munster, Munster, NRW, Germany	Robert E. Wharen, MD, Mayo Clinic, Jacksonville, FL, United States
Preoperative
Additional tests requested	fMRI MRI flowmetry MRS EEG Neuroophthalmology evaluation	None	fMRI DTI Language evaluation	fMRI Wada test Neuropsychological assessment Neurooncology evaluation
Surgical approach selected	Left temporal awake craniotomy with speech and motor mapping	Left temporal craniotomy	Left temporal awake craniotomy with 5-ALA and language mapping	Left temporal awake craniotomy with language mapping (after determining patency of shunt)
Anatomic corridor	Left temporal	Left temporal	Left temporal	Left temporal
Goal of surgery	Decompression, diagnosis	Complete resection of enhancing portion and as much FLAIR as possible	Complete safe resection of fluorescent components that typically extend past enhancement	Extensive resection of enhancing portion without neurologic compromise
Perioperative
Positioning	Left supine with 60 degree right rotation	Left supine	Left supine	Left supine
Surgical equipment	Ultrasound Brain stimulator	Surgical navigation Surgical microscope Ultrasonic aspirator	Surgical navigation Ultrasound Brain stimulator Surgical microscope with 5-ALA Ultrasonic aspirator	Surgical navigation Brain stimulator Surgical microscope
Medications	Steroids Antiepileptics	Steroids	Steroids	Steroids Antiepileptics
Anatomic considerations	Speech centers	Sylvian fissure, Wernicke, pial boundary	Wernicke, Ludders temporobasal language, IFOF, AF, choroidal fissure, internal capsule, cranial nerve 3	Speech and memory centers
Complications feared with approach chosen	Language dysfunction, upper quadrantopsia	Language dysfunction	Language dysfunction, quadrantopsia, cranial 3 palsy	Language dysfunction, memory issues
Intraoperative
Anesthesia	Asleep-awake-asleep	General	Awake-awake-awake (asleep)	Asleep-awake-asleep
Skin incision	Pterional	Question mark	Pterional	Question mark
Bone opening	Left temporal	Left temporal	Left fronto-temporal	Left temporal
Brain exposure	Left temporal	Left temporal	Left fronto-temporal	Left temporal
Method of resection	Left temporal myocutaneous flap, left temporal craniotomy with drilling down toward skull base, dural tack up sutures, awaken patient after dural opening, ultrasound to localize lesion, speech and motor mapping with cortical and subcortical stimulation, subpial anterior lobectomy, put patient back to asleep for closure	Myocutaneous flap, craniotomy based on navigation, dural opening, corticectomy anterior and low to the lesion, attempt to dissect planes, internally debulk with ultrasonic aspirator if margins are not apparent, debulk to margins, subpial dissection medially to ensure medial borders, extend resection to anterior middle fossa dura, go to floor for inferior margin, confirm posterior margin with navigation	Scalp block, position while responsive, deepen sedation for craniotomy, left temporal craniotomy, reduce sedation, dural opening, language mapping in exposed temporal cortex and find positive mapping over the Broca area, map temporal lobe, resect posterior margin based on fluorescence, then cranial and then medial and along Sylvian fissure/parahippocampal gyrus/hippocampus, subpial dissection into choroidal fissure to border of fluorescence	Preoperative scalp block, myocutaneous flap, right temporal craniotomy, cortical language mapping, enter tumor anterior ITG, resect contrast-enhancement with continuous language and memory testing
Complication avoidance	Awake motor and speech mapping, anterior temporal lobectomy, ultrasound to localize, subpial dissection	Subpial dissection, anatomic boundaries, attempted en bloc resection	Language mapping, fluorescence, subpial dissection	Language and memory mapping, enter anterior ITG
Postoperative
Admission	ICU	ICU	ICU or intermediate care	ICU
Postoperative complications feared	Language dysfunction, visual field deficit	Seizures, stroke	Language dysfunction, visual field deficit	Language dysfunction, memory loss
Follow-up testing	MRI within 48 hours after surgery	MRI within 24 hours after surgery	MRI within 48 hours after surgery	MRI within 48 hours after surgery
Follow-up visits	10 days after surgery with radiation and neurooncology	3 months after surgery	2 weeks after surgery with neuro and radiation oncology	Adjuvant therapies recommended
IDH status
Referral to neurooncology and radiation oncology	Mutant–radiation/temozolomide Wild type–radiation/temozolomide Consideration of TTF	Mutant–radiation/temozolomide +/– TTF Wild type–radiation/temozolomide +/– TTF	Mutant–determined by neuro and radiation oncology Wild type–determined by neuro and radiation oncology	MGMT status
Referral to neurooncology and radiation oncology	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide Consideration of TTF	Methylated– radiation/temozolomide +/– TTF Unmethylated–radiation/temozolomide +/– TTF	Methylated–determined by neuro and radiation oncology Unmethylated–determined by neuro and radiation oncology