Abstract
Background: Gliomas are among the most challenging pathologies for neurosurgeons due to their infiltrative and recurrent nature in functionally relevant regions. Current knowledge confirms that gross total resection highly influence survival in patient with glioma. However, surgery performed in eloquent brain area, could seriously compromise the quality of life in patient with reduced life expectancy even more if it concerns the language function. Methods: 18 right-handed patients with perisylvian gliomas on the left hemisphere were prospectively analyzed over a period of 12 months. Standardized preoperative Diffusion-Tensor-Imaging based tractography of the five main language Tracts (Arcuate Fasciculus, Frontal Aslant Tract, Inferior Fronto-Occipital Fasciculus, Inferior Longitudinal Fasciculus, Uncinate Fasciculus) was navigated during the surgical procedure. Using a validated method, correlations were made between the pre-operative fascicles and their possible infiltration and surgical damage. The language status was assessed using the Aachen Aphasia Test. Results: In all nine patients who developed a permanent disorder there was pre-operative involvement of at least one fascicle and resection of at least one of these. In this way, areas of high risk of permanent language damage have emerged as a result of surgical injury: the temporoparietal junction, the middle portion of the FAT and the temporal stem. Conclusions: Navigated tractography has proven to be a user-friendly tool that can assess perioperative risk, guide surgical resection, and help the neurosurgeon to find that balance between tumor resection and function preservation.
Highlights
Considering the demographic characteristics and overall survival of patients affected by low-grade glioma (LGG), the need to guarantee a good quality of life is unquestionable
Surgical procedures were performed for 13 high-grade gliomas, of which seven were located in the frontal lobe and six in the temporal lobe, including one with insular extension and another with involvement of the parietal lobule
Gross total resection was achieved in nine patients: seven high grade and two low grade gliomas
Summary
Considering the demographic characteristics and overall survival of patients affected by low-grade glioma (LGG), the need to guarantee a good quality of life is unquestionable. Gross total resection in case of high-grade glioma (HGG) could improve the overall survival of a few months (mean 14 months) at the expense of neurological deficits [1,2]. As the surgery needs to preserve the functionality, direct electrical stimulation (DES) in awake patient became the gold standard: performing DES mapping in awake patients with glioma in language eloquent areas results in a significant decrease of postoperative permanent aphasia and more generally of severe persistent neurological deficits [5,6,7]
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