Right temporal high-grade glioma

Introduction

A relatively common location for high-grade gliomas is the temporal lobe, in which the incidence ranges from 15% to 25% in several series. Patients with temporal lobe gliomas typically present with seizures but can have more subtle deficits in neurocognitive function, including attention, object naming, and language. ^, Although nondominant temporal lobe lesions are considered to have lower risk profiles than corresponding lesions in the dominant hemisphere, surgery can still be associated with significant morbidity. ^, In this chapter, we present a case of a right temporal lobe high-grade glioma.

Example case

Chief complaint: confusion

History of present illness

A 65-year-old, right-handed man with a history of coronary artery disease and hypertension presented with acute confusion. He was in his usual state of health until earlier this morning when he had an acute onset of confusion on awakening in which he did not know where he was or what time of day it was. This was witnessed by his wife. He was taken to the emergency room, where imaging revealed a brain lesion. He denies any loss of consciousness, arm/leg shaking, or urinary incontinence ( Fig. 24.1 ).

Medications : Lisinopril, metoprolol, aspirin.
Allergies : No known drug allergies.
Past medical and surgical history : Coronary artery disease, hypertension, cholecystectomy, appendectomy.
Family history : No history of intracranial malignancies.
Social history : Store owner, 0.5 pack/day for 30-year smoking history, social drinker.
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.

	Ricardo Díez Valle, MD, PhD, Fundación Jiménez Díaz University Clinic, Madrid, Spain	Peter Nakaji, MD, Barrow Neurological Institute, Phoenix, AZ, United States	Ian F. Parney, MD, PhD, Mayo Clinic, Rochester, MN, United States	Shota Tanaka, MD, PhD, The University of Tokyo, Tokyo, Japan
Preoperative
Additional tests requested	DTI Cardiology evaluation	DTI fMRI	None	DTI PET FDG Chest/abdomen/pelvis CT Cardiac ultrasound
Surgical approach selected	Right temporal craniotomy with 5-ALA and asleep motor mapping	Right temporal craniotomy with fluorescein	Right fronto-temporal craniotomy with possible fluorescence	Right fronto-temporal craniotomy with 5-ALA and asleep motor mapping
Anatomic corridor	Right temporal	Right ITG, MTG	Right temporal	Right temporal
Goal of surgery	Gross total resection of enhancing component guided by mapping	Maximal resection, decrease mass effect	Gross total resection of enhancing component	Gross total resection of enhancing component
Perioperative
Positioning	Right supine with 90-degree left rotation	Right supine with left rotation	Right supine with left rotation	Right supine with left rotation
Surgical equipment	Surgical navigation Surgical microscope with 5-ALA IOM (MEP) Brain stimulator	Surgical navigation IOM (MEP, SSEP) Surgical microscope with fluorescein	Surgical navigation Ultrasonic aspirator Surgical microscope +/– fluorescence	Surgical navigation IOM (MEP) Brain stimulator Surgical microscope with 5-ALA Doppler
Medications	Steroids	Steroids	Steroids Antiepileptics Mannitol	Steroids Antiepileptics Mannitol
Anatomic considerations	Basal ganglia, internal capsule, temporal horn, PCA, MCA branches	Basal ganglia, internal capsule	MCA, lateral lenticulostriate arteries, basal ganglia	CST, internal capsule
Complications feared with approach chosen	Vascular injury, damage to internal capsule	Motor deficit	Stroke	Motor deficit
Intraoperative
Anesthesia	General	General	General	General
Skin incision	Mini pterional	Linear	Pterional	Curved pterional
Bone opening	Right temporal	Right temporal	Right fronto-temporal	Right fronto-temporal
Brain exposure	Right temporal	Right temporal	Right temporal	Right fronto-temporal
Method of resection	Mini pterional incision, fascial and muscle opening in separate layers, craniotomy based on navigation, dural opening, cortical entry based on navigation and most superficial portion, debulk necrotic tumor first if brain is full, 5-ALA-guided resection, access to basal cistern to relax brain, continue debulking with forceps and bipolar, monopolar stimulation at deep and medial aspects of the tumor, resection of red fluorescence completely and pale fluorescence based on mapping, intraoperative MRI to assess for further resection	Small temporal craniotomy, intratumoral debulking, anterior temporal lobectomy, subpial removal along anterior Sylvian fissure, care along posterior and deep portions, leave residual if necessary, fluorescein to help guide additional resection	Right fronto-temporal craniotomy, dural openings, attempted en bloc resection under microscopic visualization +/– fluorescence, further resection of obvious residual +/– fluorescence	Navigation and transcranial MEP monitoring setup, right fronto-temporal craniotomy, dural opening, right temporal lobectomy with 5-ALA under microscopic visualization, further resection with subcortical stimulation at bottom of resection cavity to prevent pyramidal tract injury
Complication avoidance	Avoid ultrasonic aspirator, resection limited first to 5-ALA positive areas, cortical and subcortical asleep mapping	Anterior temporal lobectomy, subpial dissection along Sylvian fissure, caution along posterior and medial portions, fluorescein	En bloc resection, possible fluorescence-guided resection	Temporal lobectomy, 5-ALA, subcortical stimulation of CST
Postoperative
Admission	ICU	ICU	ICU	ICU
Postoperative complications feared	Motor deficit, hemianopsia	Motor deficit	Motor deficit	Stroke
Follow-up testing	MRI within 24 hours after surgery	MRI within 48 hours after surgery Physical, occupational, speech therapy	MRI within 24 hours after surgery	MRI within 48 hours after surgery
Follow-up visits	7 days after surgery	10–14 days after surgery	3 months after surgery 7 days after surgery with radiation and neurooncology	14–21 days after surgery
Adjuvant therapies recommended
IDH status	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–radiation/temozolomide Wild type–radiation/temozolomide	Mutant–possible second look surgery of FLAIR Wild type–radiation/temozolomide +/– TTF	Mutant–radiation/temozolomide Wild type–radiation/temozolomide
MGMT status	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide	Methylated–radiation/temozolomide +/– TTF Unmethylated–radiation/temozolomide +/– TTF	Methylated–radiation/temozolomide Unmethylated–radiation/temozolomide