Article
Personal surgical outcome of insular gliomas: patient selection for radical resection, surgical strategy, and tips
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Authors
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Jong Hee Chang
- Yonsei University Severance Hospital, Korea
| Published: | June 8, 2016 |
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Outline
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Objective: The insular lobe is a functionally complex structure, having peculiar anatomical and vascular features and specific neuronal connectivity with surrounding cerebral structures. Because of its complexity, surgery of insular tumors has been traditionally regarded as dangerous. Thanks to the development of modern diagnostic, neurophysiological and surgical tools, the radical resection of tumor located in insular area is possible, but insular gliomas still remain surgically challenging. We analyzed our surgical experience of insular gliomas and will discuss about the patient selection for radical resection, surgical strategy, and tips.
Method: During last 7 years, I personally operated 31 insular gliomas in 29 patients. There were 16 WHO grade II gliomas (1 oligodendroglioma, 9 oligoastrocytomas, and 6 diffuse astrocytomas), 4 grade III gliomas (1 anaplastic oligoastrocytoma, 1 anaplastic oligoastrocytoma, and 2 anaplastic astrocytomas), and 11 grade IV gliomas. The tumor was located in dominant insular lobe in 13 cases and in non-dominant in 18 cases. I did transsylvian approach in 23 patients, transcortical approach in 7, and combined approach in one. Electrical direct cortical and subcortical mapping was performed in 16 cases.
Results: Grossly total resection was possible in 14 cases and subtotal resection (more than 90%) in 15 cases. In the other 2 patients, we did just partial resection (50-90%). There were 5 asymptomatic infarction, 2 transient dysphasia, 4 transient hemiparesis, and 5 permanent hemiparesis (3 motor grade 4, 1 motor grade 3/4+, and 1 motor grade 1).
Conclusions: The surgery for insular gliomas still remains challenging, especially in the posterior part of the dominant insula and anterior perforating substance. To improve the extent of resection and reducing the risk of neurological complications in insular glioma surgery, the use of intraoperative functional mapping is essential. The use of various complimentary tools such as DTI navigation, intraoperative imaging, ICG videoangiography, 5-ALA fluorscence, and continuous MEP monitoring could be also helpful in selective cases. However, improved understanding of the surgical anatomy and function of insular area and patient selection are also important for radical resection.
