Left thalamic high-grade glioma

Introduction

The general treatment paradigm for high-grade gliomas is maximal resection followed by adjuvant chemoradiation; however, patients who develop deficits have worsened survival independent of the extent of resection. Deep-seated high-grade gliomas have arguably the highest surgical risk of developing neurologic deficits. Therefore the management of deep-seated high-grade gliomas remains unclear. Some practitioners perform stereotactic needle biopsies to minimize surgical morbidity, whereas others perform open resections with significant risk of iatrogenic deficits. ^, In this chapter, we present a case of a dominant-hemisphere thalamic high-grade glioma.

Example case

Chief complaint: right-sided arm and leg weakness

History of present illness

An 18-year-old, right-handed woman with no significant past medical history presented with progressive right arm and leg weakness. She stated that over the past 2 to 3 months her right arm has become weaker to the point where she has problems writing. In addition, her leg seems to drag more when she walks. She denies any speaking or vision problems ( Fig. 26.1 ).

Medications : None.
Allergies : No known drug allergies.
Past medical and surgical history : None.
Family history : No history of intracranial malignancies.
Social history : College student, no smoking, no alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Language: intact naming and repetition; Cranial nerves II-XII intact except slight decreased right nasolabial fold, right drift, right upper extremity 4/5, right lower extremity 4+/5, left upper extremity/left lower extremity 5/5.
Imaging : Chest/abdomen/pelvis with no evidence of primary disease.

	Frederick F. Lang, MD, MD Anderson Cancer Center, Houston, TX, United States	Fredric B. Meyer, MD, Mayo Clinic, Rochester, MN, United States	Stephen J. Price, MBBS, PhD, University of Cambridge, Cambridge, United Kingdom	Andreas Raabe, MD, University Hospital at Inselspital Bern, Switzerland
Preoperative
Additional tests requested	fMRI DTI MRV	+/– fMRI +/– DTI	DTI	DTI Neuropsychological assessment
Surgical approach selected	Left parietal craniotomy with intraoperative MRI and 5-ALA, if available	Left parietal craniotomy with asleep subcortical stimulation	Supracerebellar infratentorial	Left parietal craniotomy with tubular retractor with intraoperative MRI
Anatomic corridor	Left superior parietal lobule	Left superior parietal lobule, transsulcal, transventricular to pulvinar	Supracerebellar infratentorial	Left postcentral-intraparietal transsulcal
Goal of surgery	Complete resection of contrast-enhancing portion if possible	Extensive resection of enhancing portion of the tumor	Extensive resection of enhancing portion of the tumor	Extensive resection guided by mapping and intraoperative MRI
Perioperative
Positioning	Left supine	Right lateral with head turned to the right	Prone	Left lateral with 20-degree head tilt and turn to the right
Surgical equipment	Surgical navigation IOM (SSEP, phase reversal) Brain retractor Surgical microscope with 5-ALA, if possible Ultrasonic aspirator Intraoperative MRI	Surgical navigation IOM (MEP) Surgical microscope Brain retractor Suction brain stimulator	Surgical navigation Surgical microscope Ultrasonic aspirator Ultrasound Budde halo retractor	Surgical navigation IOM (MEP, SSEP) Ultrasound Surgical microscope with augmented reality Ultrasonic aspirator Intraoperative MRI
Medications	Steroids Antiepileptics	Steroids Antiepileptics	SteroidsMannitol	Steroids Antiepileptics
Anatomic considerations	Motor cortex, AF, internal capsule/CST	Posterior limb of internal capsule	Avoiding optic tracts and CST	Sensory pathways, AF, optic tract, thalamus, internal capsule, crus cerebri, CST, perforating arteries
Complications feared with approach chosen	Motor deficit, sensory deficit, language dysfunction	Worsening motor deficit	Motor, visual deficit	Motor, language, or visual deficit
Intraoperative
Anesthesia	General	General	General	General
Skin incision	Lateral-based U-shaped flap	Linear horizontal	Midline linear from occiput to C2 with option of hockey stick incision	Linear
Bone opening	Left parietal	Left parietal	Occipital craniotomy eccentric to the right	Left parietal
Brain exposure	Left superior parietal lobule	Left superior parietal lobule	Cerebellar hemispheres and transverse sinus	Left parietal
Method of resection	Craniotomy centered over superior parietal lobule near midline, open dura medially, phase reversal to identify perirolandic area, confirm entry point behind sensory cortex in superior parietal lobule, preserve veins, 2 x 2 cm corticectomy, follow path down to lesion with navigation, advance retractors once tumor is reached, internally debulk, dissect tumor until completely removed, intraoperative MRI for possible further resection	Craniotomy centered on selected sulcus based on navigation, dural tack up sutures, dural opening, sulcus opened and retracted with brain retractor (circular or single blade), divide U-fibers vertically, enter ventricle under navigation, choroid plexus is swept away and cottonoid placed to prevent spillage of blood products and tumor, horizontal incision in pulvinar based on appearance and stereotaxis, debulk tumor with suction and bipolar, stimulate with suction tip to identify internal capsule at 3–4 mA, continuous MEP, debulk tumor from medial to lateral, protect small perforators, avoid aggressive cauterization, water tight dural closure	Midline dissection from occiput to C1, burr holes on each side of the keel, craniotomy going up to transverse sinus eccentric to the right, Y-shaped dural opening, care of draining veins, drain CSF, depress cerebellum from tentorium, enter pineal region, corticectomy over tumor (ultrasound and image guidance), internal debulking of tumor, aim for cyst laterally, aim for subtotal resection, watertight dural closure	Left parietal craniotomy based on navigation, identification of interparietal and postcentral sulci, placement of tubular retractor, resect tumor with ultrasonic aspirator under microscopic visualization with augmented reality and continuous motor mapping, resect tumor until 3–4 mA threshold reached, intraoperative MRI with DTI, further resection until 2 mA threshold reached, repeat intraoperative MRI with DTI as needed
Complication avoidance	Phase reversal to confirm superior parietal lobule, preserve veins, navigation for trajectory, brain retractor to hold corridor, intraoperative MRI for possible further resection	Transsulcal approach, corridor kept open with retractor, cottonoid pledge to protect spillage, use of stimulating suction to identify internal capsule, continuous MEP, medial to lateral resection, avoid aggressive cauterization	Supracerebellar approach to minimize cortical entry, internally debulking of tumor, target lateral cyst	Transsulcal approach, tubular retractor, augmented reality, continuous motor mapping, intraoperative MRI with DTI
Postoperative
Admission	ICU	ICU	Floor	ICU
Postoperative complications feared	Motor weakness, language dysfunction	Progressive hemiparesis, thalamic pain syndrome	Difficulty accessing tumor, hemianopia, motor deficit, CSF leak	Motor of language deficit, seizures
Follow-up testing	MRI within 24 hours after surgery	MRI within 24 hours after surgery Physical and occupational therapy evaluation	MRI within 72 hours after surgery	MRI within 48 hours after surgery Neuropsychological assessment Visual field testing
Follow-up visits	2 weeks after surgery with neurosurgery, neurooncology, radiation oncology	6 weeks after surgery with neurosurgery 2 weeks after surgery with neurooncology and radiation oncology	7 days after surgery	4 weeks after surgery
Adjuvant therapies recommended
IDH status	Mutant–radiation followed by temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–temozolomide (GTR), temozolomide/radiation (STR) Wild type–radiation/temozolomide
MGMT status	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide