Resection of Insular Glioma Through the Transfrontal Limiting Sulcus Approach

Abstract

BACKGROUND:The current transsylvian or transopercular approaches make access difficult because of the limited exposure of insular tumors. Hence, maximal and safe removal of insular gliomas is challenging. In this article, a new approach to resect insular gliomas is presented. OBJECTIVE: To determine whether the new transfrontal limiting sulcus approach is helpful for maximal and safe removal of insular gliomas. METHODS: The authors reported surgical techniques for insular gliomas resected through the transfrontal limiting sulcus approach. The authors evaluated the surgical resections of 69 insular gliomas performed through the new approach in their department. The extents of resection and postoperative neurological outcomes were analyzed to determine the value of this new approach. RESULTS: Based on the Berger-Sanai classification, most insular gliomas were giant tumors (59.42%), followed by zone I + IV tumors (24.64%). The median (interquartile range) extent of resection of all patients was 100% (91%, 100%). The total resection rate for all gliomas was (55 of 69, 79.7%), and the total resection rate for low-grade gliomas was (28 of 40, 70%), which was significantly lower than that for high-grade gliomas (27 of 29, 93.1%) (P = .019). All patients had muscle strength greater than grade 4 3 months after surgery. Only 1 patient had a speech disorder 3 months after surgery. The median Karnofsky Performance Status score at the time of the 3-month follow-up was 90. CONCLUSION: The transfrontal limiting sulcus approach can help to achieve maximal and safe removal of insular gliomas.

Surgical treatment for insular gliomas. A systematic review and meta-analysis on behalf of the EANS neuro-oncology section

“…: 11 (13.9%), LGG: 52 (65.8%), WHO°I: 1 (1.3%), other: 0 4 (5.1%) 1 (1.3%) NA NA NA Rossi et al (2021) 95 Epilepsy: 70 (73.7%), motor deficit: 11 (11.6%), dysphasia 16 (16.8%) GBM: 19 (20.0%), anapl. : 7 (7.4%), LGG: 69 (72.6%), WHO°I: 0, other: 0 7 (7.4%) 20 (21.1%) NA 38/43 (uncontrolled seizures, 88.4%) NA Sun et al (2022) 69 Epilepsy: 38 (55.1%), motor deficit: 7 (10.1%), dysphasia: 7 (10.1%) GBM & anapl. : 29 (42.0%), LGG: 40 (58.0%) NA 1 (1.4%) NA NA NA Singh et al (2023) 27 Epilepsy: 14 (51.9%), focal deficit: 9 (33.3%), intracranial hypertension: 14 (51.9%) GBM: 27 (100%), anapl.…”

“…: 3 (11.1%) 16 (59.3%) Leroy et al (2021) 20 NA Berger-Sanai TOP, TT 0 Neuronavigation, fMRI, iopMRI: 20 (100%) 12 (60.0%) Pallud et al (2021) 149 (111 resection & 38 biopsy cases) 138/149 (92.6%) Yasargil, Berger-Sanai TOP (111, 100%) 0 Neuronavigation: 111/149 (74.5%), US, awake: 61/149 (40.9%) 21 (14.1%) Panigrahi et al (2021) 61 NA Berger-Sanai TS (38, 62.3%), TOP (23, 37.7%) 38 (62.3%) Neuronavigation, fMRI, DTI, electrostim., ICG angio: 61 (100%) 38 (62.3%) Pepper et al (2021) 38 NA Berger-Sanai NA NA iopM: 11 (28.9%), awake: 27 (71.1%) 6 (15.8%) Pitskhelauri et al (2021) 79 38 (48.1%) Berger-Sanai, Pitskhelauri classification TS (77, 97.5%), TS + TOP (2, 2.5%) 79 (100%) iopM (MEPs): 79 (100%), electrostim., awake: 2 (2.5%) 30 (38.0%) Rossi et al (2021) 95 81 (85.3%) Berger-Sanai, diffuse vs. sharp medial border, LSA, deep perforator and opercular arteries involvement TOP (95, 100%) 0 iopM (MEPs&SEPs), ECOG: 95 (100%), electrostim. : 25 (26.3%), awake: 70 (73.6%) 70 (73.7%) Sun et al (...…”

“…The rate of temporary deficits is high and several publications describe neurological improvement over time. Specifically, early motor and language deficit rates in series describing >50 surgeries varied between 8.1 - 37.5% and 4.3–50.1% ( Duffau, 2009 ; Eseonu et al, 2017 ; Hameed et al, 2019 ; Hervey-Jumper et al, 2016 ; Kawaguchi et al, 2014 ; Lang et al, 2001 ; Leroy et al, 2021 ; Li et al, 2020 ; Majchrzak et al, 2011 ; Moshel et al, 2008 ; Özyurt et al, 2003 ; Pallud et al, 2021 ; Pepper et al, 2021 ; Pitskhelauri et al, 2021 ; Przybylowski et al, 2020 ; Rao et al, 2018 ; Rossi et al, 2021 ; Sanai et al, 2010 ; Simon et al, 2009 ; Skrap et al, 2012 ; Sughrue et al, 2017 ; Sughrue et al, 2016 ; Sun et al, 2022 ; Zhuang et al, 2016 ). The majority of neurological complications seems to be caused by ischemia due to small vessel compromise, i.e.…”

“…Transtemporal and transfrontal approaches, i.e. operating insular tumors through the temporal stem following a temporal lobe resection or entering the insula through a frontal or fronto-basal corticotomy ( Simon et al, 2009 ; Sun et al, 2022 , 2023 ), were described later on reflecting growing experience with surgery for large tumors with extrainsular extensions. Transsylvian surgery involves often significant manipulation of the vasculature of the Sylvian fissure with an attendant risk for vascular injuries ( Lang et al, 2001 ; Przybylowski et al, 2021 ).…”

“…Neurological deficits were not reported in a standardized manner and often reported for different time points or without mentioning the time point at all. In contrast to others ( Di Carlo et al, 2020 ; Lu et al, 2019 ) we therefore decided against studying temporary deficits – which frequently occur following insular tumor surgery ( Duffau, 2009 ; Eseonu et al, 2017 ; Hameed et al, 2019 ; Hervey-Jumper et al, 2016 ; Kawaguchi et al, 2014 ; Lang et al, 2001 ; Leroy et al, 2021 ; Li et al, 2020 ; Majchrzak et al, 2011 ; Moshel et al, 2008 ; Özyurt et al, 2003 ; Pallud et al, 2021 ; Pepper et al, 2021 ; Pitskhelauri et al, 2021 ; Przybylowski et al, 2020 ; Rao et al, 2018 ; Rossi et al, 2021 ; Sanai et al, 2010 ; Simon et al, 2009 ; Skrap et al, 2012 ; Sughrue et al, 2017 ; Sughrue et al, 2016 ; Sun et al, 2022 ; Zhuang et al, 2016 ).…”