Right frontal high-grade glioma

Introduction

The factors associated with worse outcomes for patients with high-grade gliomas include older patients, poorer neurologic function, tumors in close proximity to the subventricular zone, and decreasing extent of resection. In several studies, increasing extent of resection is associated with prolonged survival and delayed recurrence; however, the development of neurologic deficits reverses the benefits of extent of resection. ^, ^, In general, lesions in the right frontal lobe are amenable to extensive resection, as they are more remote from eloquent brain regions. In this chapter, we present a case of a right frontal likely high-grade glioma.

Example case

Chief complaint: seizures

History of present illness

A 73-year-old, right-handed woman with a history of aneurysmal subarachnoid hemorrhage s/p coil embolization presented with seizures. She was with her family when she developed acute onset of left twisting of her body, left-sided head turn, and unresponsiveness. She was brought to the emergency room, where imaging revealed a brain lesion ( Fig. 15.1 ).

Medications : None.
Allergies : No known drug allergies.
Past medical and surgical history : right paraophthalmic aneurysm coil 7 years prior.
Family history : No history of intracranial malignancies.
Social history : Retired school teacher, remote smoking history, occasional 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.
Imaging : Chest/abdomen/pelvis computed tomography negative for primary malignancy.

	Chetan Bettegowda, MD, PhD, Johns Hopkins University, Baltimore, MD, United States	Orin Bloch, MD, University of California-Davis, Sacramento, CA, United States	Guilherme C. Ribas, MD, PhD, Hospital Israelita Albert Einstein, São Paulo, Brazil	Walter Stummer, MD, PhD, University of Munster, Munster, NRW, Germany
Preoperative
Additional tests requested	CT angiogram MRS	MRS Neurooncology evaluation	MRS MR perfusion	FET PET fMRI
Surgical approach selected	Right frontal craniotomy	Right pterional craniotomy with asleep cortical and subcortical motor mapping	Right frontal temporal craniotomy	Right frontal craniotomy with 5-ALA and asleep cortical and subcortical motor mapping
Anatomic corridor	Right frontal	Right frontal	Right frontal	Right frontal SFG, MFG, STG
Goal of surgery	Gross total resection	Attempted supratotal resection	Maximal resection	Maximal safe resection, biopsy fluorescent areas for representative histology
Perioperative
Positioning	Right supine	Right supine left head rotation	Right supine with left head rotation	Right supine left 60-degree head rotation
Surgical equipment	Surgical navigation IOM (SSEP, EEG) Surgical microscope	Surgical navigation IOM (MEP) Ultrasonic aspirator	Surgical navigation Ultrasound Ultrasonic aspirator	Surgical navigation IOM (MEP) Ultrasound Surgical microscope with 5-ALA Ultrasonic aspirator
Medications	Steroids Antiepileptics Mannitol	Steroids Antiepileptics Mannitol	Antiepileptics	Steroids
Anatomic considerations	Frontal sinus, aneurysm	Primary motor cortex (face), SMA, subcortical CST, lateral ventricle, MCA and lenticulostriates	Sylvian fissure, inferior frontal gyrus convolutions	Primary motor cortex
Complications feared with approach chosen	Inadvertent aneurysm injury	Motor deficit, stroke	Typical postoperative complications	Tongue weakness, dysarthria, vascular injury
Intraoperative
Anesthesia	General	General	General	General
Skin incision	Pterional	Right linear coronal	Pterional	Pterional
Bone opening	Right frontal	Right fronto-temporal	Right fronto-temporal	Right fronto-temporal
Brain exposure	Right frontal	Right fronto-temporal	Right fronto-temporal	Right fronto-temporal
Method of resection	Right frontal craniotomy guided by navigation, C-shaped dural opening, navigation-guided sampling of contrast enhancing areas, resection of FLAIR abnormality, ultrasound to evaluate for extent of resection and need for additional resection	Separate dissection of temporalis muscle, fronto-temporal craniotomy, dural opening, identify boundaries based on navigation, asleep mapping of face and upper extremity to find primary motor cortex, sample tumor in center, perform corticectomy and subcortical dissection beyond tumor margin if possible, subpial resection posteriorly adjacent to primary motor cortex, debulk tumor with ultrasonic aspirator, open into ventricle for anatomic localization, remove tumor en bloc, place EVD at posterior aspect of tumor margin, subgaleal drain	Wide right fronto-temporal craniotomy with large exposure of the frontal lobe especially its antero-lateral basal aspect, drill outer aspect of the sphenoid wing, wide dural opening with exposure of frontal and temporal operculi, anatomic identification of the exposed sulci and gyri especially including inferior frontal and lateral orbital gyri with aid of neuronavigation and ultrasound, open Sylvian fissure especially of stem, dissect tumor from superior and posterior margins, removal of tumor with dissection and suction with aid of ultrasonic aspirator, outer to inner debulking	Tailored craniotomy to lesion boundaries based on navigation, MEP mapping of cortex (<10 mA) and subcortical space (<20 mA) with monopolar stimulator, biopsy hot spots based of FET PET and fluorescence, subpial dissection at Sylvian fissure and SFS with subcortical mapping, resect posterior portion of tumor with constant monopolar subcortical simulation to identify CST, ultrasound and microscope for deep portion of the tumor
Complication avoidance	IOM	IOM, cortical and subcortical mapping, subpial dissection at posterior aspect of tumor, en bloc resection, EVD	Wide bony opening, anatomic landmark identification, outer to inner debulking	Cortical and subcortical mapping, subpial dissection, ultrasound and fluorescence to guide resection
Postoperative
Admission	ICU	ICU	ICU	ICU or intermediate care
Postoperative complications feared	Abulia, motor deficit, CSF leak	Motor deficit, stroke, hydrocephalus	General postoperative complications	Motor deficit including tongue and face
Follow-up testing	MRI within 24 hours after surgery Physical and occupational therapy	MRI within 48 hours after surgery	MRI within 48 hours after surgery	MRI within 48 hours after surgery
Follow-up visits	14 days after surgery	14 days after surgery	2–3 months after surgery	3 months after surgery
Adjuvant therapies recommended
IDH status	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide +/– TTF Wild type–radiation/temozolomide +/– TTF
MGMT status	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide +/– TTF Unmethylated–radiation/temozolomide +/– TTF