Abstract
Background
If an awake surgery is somehow not available for gliomas at the language area, understanding the anatomy and well-designed surgical strategy are important.
Method
We present a case with left hemispheric multifocal high-grade gliomas located deeply at the left temporal pole, the Wernicke’s area, and mesial temporal region. Because the patient could not endure the awake surgery and obtain practicable functional magnetic resonance imaging (MRI) for eloquent cortex evaluation, we removed the lesions following the anatomical resection strategy guided by diffusion tensor imaging (DTI).
Conclusion
This case demonstrates the value of DTI and the importance of anatomical resection strategies in glioma surgeries.
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Acknowledgments
The DTI images in this manuscript were reconstructed using an automatic algorithm software “Diffusion Go”.
Funding
This study was supported by the Outstanding Academic Leaders Program of Shanghai Municipal Commission of Health and Family Planning (No. 2017BR006 to W.Z.), and the Shanghai Rising-Star Program (No. 18QA1400900 to J.P.S.)
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It represents a video of a surgical case. The next of kin of the patient gave approval for this publication
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Key points
1. For high-grade gliomas, the goal of the surgery should be maximal safe resection with function preservation.
2. General anesthesia may be a rational option, if the patient cannot cooperate or tolerate the prolonged awake surgery with already-existed aphasia.
3. If an awake surgery is not available for glioma affecting language area, understanding the anatomy and well-designed surgical strategy are important.
4. A detailed preoperative neurological and neuroimaging evaluation is mandatory.
5. DTI is important to evaluate the speech-related white matter tracks and surgical approach planning.
6. The superior longitudinal fasciculus, arcuate fasciculus, and the inferior fronto-occipital fasciculus are the most important speech-related white matter tracks.
7. Anatomical resection rule is important in glioma surgeries.
8. Use transcortical approach for better deep-seated tumor exposure and subcortical neurofiber tracks preservation instead of trans-white matter methods.
9. Securing the en passage arteries before piecemeal tumor resection is the key step for tumor bleeding control.
10. Intra- and post-operative vasospasm of the en passage arteries may occur and should not be neglected.
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Supplementary Information
701_2020_4637_MOESM1_ESM.mp4
ESM Video This video illustrates a case of multifocal high-grade glioma affecting the language area, which was successfully treated by anatomical resection in a non-awake surgery (MP4 150 mb)
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Yang, Z., Song, J. & Zhu, W. How I do it? Anatomical multifocal high-grade glioma resection. Acta Neurochir 163, 953–957 (2021). https://doi.org/10.1007/s00701-020-04637-7
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DOI: https://doi.org/10.1007/s00701-020-04637-7