Insular Gliomas Research Articles

Surgical Anatomy and Operative Technique for Insular Glioma

Surgical Anatomy and Operative Technique for Insular Glioma

Frameless Stereotactic Navigation during Insular Glioma Resection using Fusion of Three-Dimensional Rotational Angiography and Magnetic Resonance Imaging

Perioperative cerebral infarction is a potential complication of glioma resection, of which insular tumors are at higher risk because of the proximity of middle cerebral artery branches, including the lateral lenticulostriates and long insular arteries. In this study, 3 patients received three-dimensional rotational angiography, which was fused with magnetic resonance imaging (MRI) for frameless stereotactic navigation during dominant-hemisphere insular glioma resection. All patients obtained a preoperative catheter angiogram with a three-dimensional rotational acquisition of the ipsilateral internal carotid artery. The pixel-based axial three-dimensional angiography data, thin-cut structural MRI, tractography from diffusion tensor imaging, and expressive language activation from functional MRI were uploaded into the iPlan software (Brainlab, Heimstetten, Germany) and fused. The target tumor, regional blood vessels, adjacent functional areas, and their associated fiber tracts were segmented and overlaid on the appropriate MRI sequence. This image fusion was used preoperatively to visualize the relationship of the mass with the adjacent vasculature and intraoperatively for frameless stereotactic navigation to optimize preservation of arterial structures. Three patients aged 27-60 years with excellent baseline functional status presented with seizures and were found to have a large dominant-hemisphere T2 hyperintense nonenhancing insular mass. Surgical resection was performed using multimodality neuronavigation. None sustained a postoperative arterial infarction or a perioperative neurologic deficit. Neuronavigation using a fusion of three-dimensional rotational angiography with MRI is a technique that can be used for preoperative planning and during resection of insular gliomas to optimize preservation of adjacent arteries.

Neuro-radiological characteristics of adult diffuse grade II and III insular gliomas classified according to WHO 2016.

The phenotypic heterogeneity of diffuse gliomas is still inconsistently explained by known molecular abnormalities. Here, we report the molecular and radiological features of diffuse grade WHO II and III gliomas involving the insula and its potential impact on prognosis. Clinical, pathological, molecular and neuro-radiological features of 43 consecutive patients who underwent a surgical resection between 2006 and 2013 for a grade II and III gliomas involving the insula was retrospectively analyzed. Median age was 44.4years. Eight patients had oligodendrogliomas, IDH mutant (IDHmut) and 1p/19q-codeleted (6 grade II, 2 grade III). Twenty-eight patients had diffuse astrocytomas, IDHmut (22 grade II and 6 grade III) and seven patients had grade II diffuse astrocytomas, IDHwt (A-IDHwt). Vimentin staining was exclusively recorded in tumor cells from A-IDHwt (p = 0.001). Mean cerebral blood volume (CBV) (p = 0.018), maximal value of CBV (p = 0.017) and ratio of the corrected CBV (p = 0.022) were lower for A-IDHwt. Volumetric segmentation of ADC allowed the identification of the tumor cores, which were smaller in A-IDHwt (p < 0.001). The tumor occurrences of A-IDHwt were exclusively located into the temporo-insular region. Median progression-free survival (PFS) and overall survival (OS) were 50.9months (95% CI: 26.7-75.0) and 80.9months (60.1-101.6). By multivariate analysis, A-IDHwt (p = 0.009; p = 0.019), 7p gain and 10q loss (p = 0.009; p = 0.016) and vimentin positive staining (p = 0.011; p = 0.029) were associated with poor PFS and OS respectively. Insular low-grade A-IDHwt presented with poor prognosis despite a smaller tumor core and no evidence of increased perfusion on MR imaging.

Insular glioma surgery: an evolution of thought and practice.

OBJECTIVEThe goal of this article is to review the history of surgery for low- and high-grade gliomas located within the insula with particular focus on microsurgical technique, anatomical considerations, survival, and postoperative morbidity.METHODSThe authors reviewed the literature for published reports focused on insular region anatomy, neurophysiology, surgical approaches, and outcomes for adults with World Health Organization grade II-IV gliomas.RESULTSWhile originally considered to pose too great a risk, insular glioma surgery can be performed safely due to the collective efforts of many individuals. Similar to resection of gliomas located within other cortical regions, maximal resection of gliomas within the insula offers patients greater survival time and superior seizure control for both newly diagnosed and recurrent tumors in this region. The identification and the preservation of M2 perforating and lateral lenticulostriate arteries are critical steps to preventing internal capsule stroke and hemiparesis. The transcortical approach and intraoperative mapping are useful tools to maximize safety.CONCLUSIONSThe insula's proximity to middle cerebral and lenticulostriate arteries, primary motor areas, and perisylvian language areas makes accessing and resecting gliomas in this region challenging. Maximal safe resection of insular gliomas not only is possible but also is associated with excellent outcomes and should be considered for all patients with low- and high-grade gliomas in this area.

Letter to the Editor Regarding “Autonomic Function in Insular Glioma: An Exploratory Study”

Letter to the Editor Regarding “Autonomic Function in Insular Glioma: An Exploratory Study”

Seizure Outcome After Surgical Resection of Insular Glioma.

A majority of patients with insular tumors present with seizures. Although a number of studies have shown that greater extent of resection improves overall patient survival, few studies have documented postoperative seizure control after insular tumor resection. To (1) characterize seizure control rates in patients undergoing insular tumor resection, (2) identify predictors of seizure control, and (3) evaluate the association between seizure recurrence and tumor progression. The study population included adults who had undergone resection of insular gliomas between 1997 and 2015 at our institution. Preoperative seizure characteristics, tumor characteristics, surgical factors, and postoperative seizure outcomes were reviewed. One-hundred nine patients with sufficient clinical data were included in the study. At 1 yr after surgery, 74 patients (68%) were seizure free. At final follow-up, 42 patients (39%) were seizure free. Median time to seizure recurrence was 46 mo (95% confidence interval 31-65 mo). Multivariate Cox regression analysis revealed that greater extent of resection (hazard ratio = 0.2899 [0.1129, 0.7973], P = .0127) was a significant predictor of seizure freedom. Of patients who had seizure recurrence and tumor progression, seizure usually recurred within 3 mo prior to tumor progression. Repeat resection offered additional seizure control, as 8 of the 22 patients with recurrent seizures became seizure free after reoperation. Maximizing the extent of resection in insular gliomas portends greater seizure freedom after surgery. Seizure recurrence is associated with tumor progression, and repeat operation can provide additional seizure control.

Awake Brain Mapping in Dominant Side Insular Glioma Surgery: 2-Dimensional Operative Video.

Awake Brain Mapping in Dominant Side Insular Glioma Surgery: 2-Dimensional Operative Video.

P01.074 Interest of QuID-7 for insular localization gliomas

P01.074 Interest of QuID-7 for insular localization gliomas

Long-term clinical and seizure outcomes of insular gliomas via trans-opercular approach

ObjectiveTo report long-term clinical and seizure outcomes of patients who were operated upon insular gliomas via trans-opercular approach. Patients and MethodsSince 2010, surgical resection of insular gliomas was performed via trans-opercular approach by our group. Clinical, surgical and follow-up results were analyzed retrospectively. ResultsThe majority were low-grade (81.8%) and among them oligodendroglioma was the most common (n = 8). Half of the patients underwent awake craniotomy with cortical electrical stimulation and total removal was achieved in 6 patients. Long-term follow-up showed the majority of patients (90.9 %) were completely seizure free. Only one patient showed slight paresis on one upper extremity at the long-term follow-up. ConclusionsTrans-opercular approach for insular gliomas is safe and maximal resection with minimal neurological deficits is possible. Use of ultrasonic aspirator and neuronavigation make surgery safer. Surgery-related complication is very rare. Future studies should contain larger number of patient and long-term follow-up in order to provide more accurate data.

Autonomic Function in Insular Glioma: An Exploratory Study

Autonomic nervous system dysfunction is a known entity in strokes involving insula. It causes significant morbidity and mortality. No study to date has demonstrated autonomic nervous system dysfunction in patients with insular glioma. This is an exploratory study to identify the subclinical autonomic dysfunctions in insular glioma. A total 50 patients with newly diagnosed insular glioma in the age group of 18-60 years were evaluated with heart rate variability (HRV). All the HRV parameters in patients with insular glioma were compared with normal healthy age- and sex-matched control patients. There was a significant difference (P < 0.05) in most of the HRV parameters between patients and control patients. Patients with left insular glioma showed significantly increased heart rate (P= 0.027), low-frequency normalized units (P= 0.048), and also increased low-frequency/high-frequency ratio (P= 0.015), which indicates sympathetic dominance. Patients with seizures had significantly lower values of total power (P= 0.042). No significant difference was found in terms of the extent and size of the tumor or histopathologic grades of gliomas. Patients with insular gliomas have significant impairment of autonomic functions, with left insular glioma showing sympathetic dominance. Suppression of autonomic function is greater in those presenting with seizures.

Application of intraoperative MRI combined with neuronavigation in microsurgical resection for insular glioma

To evaluate the value of intraoperative magnetic resonance imaging (iMRI) combined with neuronavigation for the resection of insular gliomas. Methods: From August 2014 to October 2017 in the First Hospital Affiliated to Sun Yat-sen University, clinical data of 41 patients with insular glioma, who underwent the surgery assisted with 3.0T iMRI and neuronavigation, were analyzed retrospectively, and the resection extent, complications and prognosis were evaluated. Results: Subtotal tumor resection was achieved in 21 patients and partial resection was done in 20 after iMRI scanning. After further resection, total tumor resection was achieved in 16 patients, subtotal resection in 18 and partial resection in 7. There was a statistical significant difference in tumor resection between pre-iMRI and post-iMRI according to the Fisher test (P<0.05). In the follow-up from 3 months to 3 years, the symptoms of the 41 patients had improved. Conclusion: iMRI corrected the shift of brain. Neuronavigation can accurately and timely assess the degree of resecting tumor. The combination of neuronavigation with surgery can maximally and safely resect insular glioma.

MRI venous architecture of insula

PurposeThe purpose of this paper is to describe the venous anatomy of the insula using conventional MR brain imaging and confocal reconstructions in cases with glioma induced venous dilatation (venous gliography). MethodsRoutine clinical MRI brain scans that included thin cut (1.5–2 mm) post contrast T1 weighted imaging were retrospectively reviewed to assess the insular venous anatomy in 19 cases (11 males and 8 females) with insular gliomas. Reconstruction techniques (Anatom-e and Osirix) were used to improve understanding of the venous anatomy. ResultsWe identified the following insular and peri-insular veins on MRI: the superficial middle cerebral vein (SMCV), peri-insular sulcus vein, vein of the anterior limiting sulcus, the precentral, central, and posterior sulcus veins of the insula, the communicating veins and deep MCV. ConclusionsWe concluded that venous anatomy of insula is complicated and is often overlooked by radiologists on MR brain imaging. Use of confocal imaging in different planes helped us to identify the superficial and deep middle cerebral veins and their relationship to the insula. The understanding of the insular venous architecture is also useful to distinguish these vessels from insular arteries. This knowledge may be helpful for presurgical planning prior to insular glioma resection.

Endoscopic Approach of the Insula Through the Anterior Middle Temporal Gyrus: A Feasibility Study in the Laboratory.

Insular glioma surgery still represents a challenge. Nonetheless, advances in microsurgical anatomy and brain mapping techniques have allowed an increase in the extent of resection with acceptable morbidity rates. Transsylvian and transcortical approaches constitute the main surgical corridors, the latter providing considerable advantages and a high degree of reliability. Nevertheless, both surgical corridors yield remarkable difficulties in reaching the most posterior insular region. To study the feasibility of an endoscopic transtemporal approach in brain specimens, with the aim to provide a suitable access for posterior insular region. Four postmortem human hemispheres, embalmed using Klingler's technique, were dissected by means of a 30° rigid endoscope. The specimens underwent magnetic resonance imaging scans and, using the neuronavigation system, we were able to design a safe cortical window and an optimized endoscopic trajectory for the posterior insular dissection. Insular dissection was led subpially through a small 2-cm cortical access, located in the anterior part of the middle temporal gyrus. During the posterior insula dissection, the endoscope allowed for optimized surgical view all along the long gyri, up to the posterior insular point. Anterior insular dissection was accomplished with more difficulties, as the endoscopic trajectory was not aligned to the axis of the short gyri. This new surgical approach provides a favorable transcortical access to reach the most posterior insular portion. It seems to be a promising tool, in combination with intraoperative functional brain mapping, to further improve extent of resection rates in insular glioma surgery.

Molecular profiles for insular low-grade gliomas with putamen involvement.

The newly proposed putamen classification system shows good prognostic value in patients with insular LGGs, yet no study towards the molecular profiles of putamen involved LGGs has been proposed. Clinical information and imaging data of patients diagnosed with insular low-grade gliomas were collected retrospectively. Genetic information of the 34 tumors was assessed using RNA-sequencing. Gene set enrichment analysis was further performed to identify the genes showing differential expression between putamen-involved tumors and putamen non-involved tumors. The level of Ki-67 expression was also evaluated. There were 843 genes identified to be differentially expressed between putamen-involved and non-involved gliomas. Specifically, Gene set enrichment analysis discovered 13 Kyoto Encyclopedia of Genes and Genomes pathways and 37 Gene Ontology Biological Process term were upregulated in putamen-involved low-grade glioma cells. The enriched GO sets with the highest gene counts included cell cycle (42 genes), mitotic cell cycle (24 genes), and cell division (19 genes). Furthermore, high expression of Ki-67 was associated with putamen involvement in insular gliomas. There is clear genetic variation between putamen-involved and non-involved insular low-grade gliomas. The differential expression of genes related to the processes of cell proliferation, cell migration, or DNA repair may lead to putamen involvement. The findings suggest that among the two subtypes, putamen-involved insular low-grade gliomas have higher malignancy, and the clinical treatment towards the putamen-involved insular low-grade gliomas should be more active.

Understanding the correlates of manic episode in a woman with insular glioma

Understanding the correlates of manic episode in a woman with insular glioma

A novel acute phase rehabilitation approach: Vibration therapy in insular glioma patients

Acute phase rehabilitation has beneficial effects on functional results, activities of daily living, mobility and cognition in glioma patient. Two insular glioma patients had acute phase rehabilitation were presented in this study. The Karnofsky Performance Scale, The Stroke Rehabilitation Assesment of Movement Scale, the Berg Balance Scale, and the Functional Independence Measure were used to assess patients. While Case 1 was treated with Neurodevelopmental Therapy (Bobath approach) (12 sessions), Case 2 was treated with cervical vibration in addition to Neurodevelopmental Therapy (15 sessions). Besides observing positive developments in the balance and functional levels of the two cases after treatment, there was more improvement in the balance parameter of Case 2. As a result of the study, cervical vibration application in addition to the rehabilitation program of patients with insular tumor could be useful in terms of balance development.

Microsurgery of Insular Gliomas: Part IV—Surgical Treatment and Outcome

Microsurgery of Insular Gliomas: Part IV—Surgical Treatment and Outcome

Microsurgery of Insular Gliomas: Part IV—Surgical Treatment and Outcome

Yaşargil, M. Gazi MD; Krisht, Ali F. MD; Türe, Ugur MD; Al-Mefty, Ossama MD; Yaşargil, Dianne C.H. RN Author Information

Surgery of Insular Gliomas.

For a long time, surgery within the insular lobe, especially in cases of intrinsic tumors, was considered as too dangerous. Even though such interventions are still challenging, resection of insular glioma became more popular during the past decade. First of all, this has happened due to better understanding of the functional anatomy of this complex brain region, combined with an improved knowledge of its connectivity. Furthermore, development of advanced intraoperative techniques, especially functional brain mapping with direct electrical stimulation, resulted in increased safety of procedures. Finally, recent evidence-based data from multiple clinical studies strongly support early maximal safe resection of both low- and high-grade gliomas. These conceptual and methodological advances led neurosurgeons to envision surgical strategy for insular gliomas in a more systematic manner.

Awake craniotomy versus craniotomy under general anesthesia for the surgical treatment of insular glioma: choices and outcomes

Objective: To investigate differences in outcomes in patients who underwent surgery for insular glioma using an awake craniotomy (AC) vs. a craniotomy under general anesthesia (GA).Methods: Data from patients treated at our hospital between 2005 and 2015 were analyzed retrospectively. The preoperative, intraoperative, postoperative, and longer term follow-up characteristics and outcomes of patients who underwent surgery for primary insular glioma using either an AC or GA were compared.Results: Of the 52 identified patients, 24 had surgery using an AC and 28 had surgery under GA. The extent of resection was similar for the two anesthesia techniques: the median extent of resection was 61.4% (IQR: 37.8–74.3%) in the WHO grade <4 AC group vs. 50.5% (IQR: 35.0–71.2%) in the grade <4 GA group and 73.4% (IQR: 54.8–87.2%) in the grade 4 AC group vs. 88.6% (IQR: 61.2–93.0%) in the grade 4 GA group. Consistent with literature, there were more early neurological deficits after an AC, while the GA group showed more new late neurological deficits; however, these trends were not significant. Survival was similar between the two groups, with 100% 1- and 2-year survival in the grade <4 groups.Conclusion: Our results showed that the extent of resection, neurological outcomes, and survival were similar using the two anesthesia techniques. Since AC is more challenging for the patient and for his or her caregiver after surgery, this finding has implications for clinical decision-making.