Application of awake craniotomy and intraoperative brain mapping for surgical resection of insular gliomas of the dominant hemisphere

• Published in: World neurosurgery Vol. 92; pp. 151 - 158
• Main Authors: Alimohamadi, Maysam, MD, PhD, Shirani, Mohammad, MD, Shariat-Moharreri, Reza, MD, Pour-Rashidi, Ahmad, MD, Ketabchi, Mehdi, MD, Khajavi, Mohammadreza, MD, Arami, Mohamadali, MD, Amirjamshidi, Abbas, MD, MPH
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-08-2016
• Subjects: Adult; Aged; Awake craniotomy; Brain Mapping; Brain Neoplasms - diagnostic imaging; Brain Neoplasms - surgery; Cerebral Cortex - diagnostic imaging; Cortical stimulation; Craniotomy - methods; Dominance, Cerebral; Electric Stimulation; Electromyography; Evoked Potentials, Motor - physiology; Female; Glioma; Glioma - diagnostic imaging; Glioma - surgery; Humans; Insula; Insular glioma; Magnetic Resonance Imaging; Male; Middle Aged; Monitoring, Intraoperative; Neurosurgery; Wakefulness; brain mapping; awake craniotomy; glioma; cortical stimulation; insula; insular glioma; Awake craniotomy; MRI; Brain mapping; Cortical stimulation; Insula; HGG; LGG; fMRI; Insular glioma; DES; Glioma; DTI; MEP; LAIR
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2016.04.079

Abstract Background Radical resection of dominant insular gliomas is difficult due to their close vicinity with internal capsule, basal ganglia and speech centers. Brain mapping techniques can be used to maximize extent of tumor removal and minimize postoperative morbidities by precise localization of eloquent cortical and subcortical areas. Methods Patients with newly diagnosed gliomas of dominanat insula were enrolled. The exclusion criteria were severe cognitive disturbances, communication difficulty, older than 75 years, severe obesity, difficult airways for intubation and severe cardiopulmonary diseases. All were evaluated by contrast enhanced brain MRI, functional brain MRI and diffusion tensor tractography of language and motor systems preoperatively. All were operated under awake craniotomy with the same anesthesiology protocol. Intraoperative monitoring included continuous motor evoked potential, electromyography, electrocorticography, direct electrical stimulation of cortex and subcortical tracts. They were followed with serial neurological examination and imaging. Results Ten patients were enrolled (4 man, 6 women) with mean age of 43.6 years. 7 patients suffered from low grade and 3 from high grade glioma. The most common clinical presentation was seizure followed by speech disturbance, hemiparesis and memory loss. Extent of tumor resection ranged from 73 to 100%. No mortatlity or new major postoperative neurological deficit was encountered. Seizure control improved in 3/4 of patients with medical refractory epilepsy. In One patient with speech disorder at presentation, the speech problem became worse after surgery Conclusion Brain mapping under awake craniotomy helps to maximize extent of tumor resection while preserving neurological function in patients with dominant insular lobe glioma.