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

Due to their deep location, surgical resection of insular tumors in the dominant hemisphere poses a significant risk of postoperative motor and language deficits. Here, we demonstrate our technique encompassing multimodal imaging guidance and awake brain mapping that enables maximum safe resection of insular gliomas. The patient, a 35-yr-old man, presented with intermittent seizures for 2 mo. Preoperative magnetic resonance imaging (MRI) revealed a nonenhancing lesion in the left insular lobe. Three-dimensional magnetic resonance spectroscopy was used to analyze the choline/N-acetyl-aspartate index, which strongly suggested a low-grade glioma diagnosis. In surgery, awake modified pterional craniotomy was performed. The mouth motor, speech arrest, and word generation areas were mapped via direct cortical stimulation. Strip electrode was placed across the precentral gyrus for continuous motor evoked potential monitoring. Noneloquent cortical incisions were made longitudinally, away from the sulci, to preserve sulcal vessels, instead of Sylvian fissure splitting. The tumor was carefully subpial debunked with Cavitron Ultrasonic Surgical Aspirator. We gradually reached the borders of resection: limen insula, anterior peri-insular sulcus, inferior peri-insular sulcus, superior peri-insular sulcus, and posterior insular point. The first branch of the lenticulostriate artery marked the medial plane of dissection. Subcortical mapping combined with diffusion tensor imaging tractography-based navigation was performed to localize the motor pathway. Intraoperative MRI evaluation showed residual tumor that was reinspected and resected. Pathological studies revealed “astrocytoma” (World Health Organization Grade II). Finally, a 96% volumetric resection was confirmed, and the patient recovered without language or motor deficits 2 wk later. Images and Video, © 2017 Department of Neurosurgery, Huashan Hospital, Fudan University. Used with permission.Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opx299 {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Awake Brain Mapping in Dominant Side Insular Glioma Surgery: 2-Dimensional Operative Video","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_y65307cf"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Disclosures This project was funded by National Natural Science Foundation of China. (Grant No. 81401546). The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.