Surgery for gliomas involving the left inferior parietal lobule: new insights into the functional anatomy provided by stimulation mapping in awake patients

Clinical article

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Object

Surgery in the left dominant inferior parietal lobule (IPL) is challenging because of a high density of somatosensory and language structures, both in the cortex and white matter. In the present study, on the basis of the results provided by direct cerebral stimulation in awake patients, the authors revisit the anatomofunctional aspects of surgery within the left IPL.

Methods

Fourteen consecutive patients underwent awake craniotomy for a glioma involving the left IPL. Intraoperative motor, sensory, and language mapping was performed before and during the tumor removal, at both the cortical and subcortical levels, to optimize the extent of resection, which was determined based on functional boundaries. Anatomofunctional correlations were performed by combining the results of intraoperative mapping and those provided by pre- and postoperative MR imaging.

Results

At the cortical level, the primary somatosensory area (retrocentral gyrus) limited the resection anteriorly in all cases, at least partially. Less frequently, speech arrest or articulatory problems were observed within the parietal operculum (4 cases). The lateral limit was determined by language sites that were variably distributed. Anomia was the most frequent response (9 cases) at the posterior third of the superior (and/or middle) temporal gyrus. Posteriorly, less reproducible reorganized language sites were seldom observed in the posterior portion of the angular gyrus (2 cases). At the subcortical level, in addition to somatosensory responses due to stimulation of the thalamocortical pathways, articulatory disturbances were induced by stimulation of white matter in the anterior and lateral part of the surgical cavity (11 cases). This tract anatomically corresponds to the horizontal portion of the lateral segment of the superior longitudinal fascicle (SLF III). Deeper and superiorly, phonemic paraphasia was the main language disturbance (12 cases), elicited by stimulation of the posterosuperior portion of the arcuate fascicle. All these eloquent structures were surgically preserved. Despite slight cognitive disorders (working memory, writing, or calculation) in 6 cases, no patient retained a severe or a moderate postoperative deficit (except one with right hemianopia [mean follow-up 41.8 months]). Resection was total or near total in 9 patients and partial in 3 cases.

Conclusions

To the authors' knowledge, this is the first series dedicated to the surgery of gliomas involving the left IPL. Interestingly, a certain degree of interindividual variability was observed in the distribution of the cortical maps, especially for language. Therefore, it is suggested that no rigid pattern of resection can be considered within the left IPL, and that surgery in this region should be performed in awake patients to adapt the tumor removal to individual functional limits. Nonetheless, several landmarks have been regularly identified, especially at the subcortical levels (SLF III and arcuate fascicle); a better knowledge of these functional tracts could be helpful to optimize functional outcomes.

Abbreviations used in this paper: DO 80 = picture-naming test; DT = diffusion tensor; IPL = inferior parietal lobule; IPS = intraparietal sulcus; SLF = superior longitudinal fascicle; SLF III = lateral fibers of the horizontal portion of the SLF; SMG = supramarginal gyrus; SPL = superior parietal lobule; T1p = posterior portion of the superior temporal gyrus; T2p = posterior portion of the middle temporal gyrus.

Article Information

Address correspondence to: Hugues Duffau, M.D., Ph.D., Département de Neurochirurgie, Hôpital Gui de Chauliac, CHU Montpellier, 80 Avenue Augustin Fliche, 34295 Montpellier, France. email: h-duffau@chu-montpellier.fr.

Please include this information when citing this paper: published online June 24, 2011; DOI: 10.3171/2011.5.JNS112.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 4. Intraoperative view of functional cortical mapping before tumor resection. The patient's head is turned to the right. The tags with the letters A–F represent the boundaries of the tumor as identified by ultrasonography. The numbered tags mark functional sites detected by direct cerebral stimulation under local anesthesia. In order from right to left: 1 = primary motor area of the face (precentral gyrus); 10 = speech arrest during counting (parietal operculum) and dysesthesias (sensory zones, postcentral gyrus); 2 = tongue; 9 = lips; 3 and 4 = hand (lateral portion) and fingers (thumb and index); 6 and 7 = hand (medial portion); 8 = forearm; 11 and 13 = speech apraxia; 14 = anomia and semantic paraphasias (T1p–SMG transition); and 12 = syntactical problems (T2p).

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    Summary of sites where language interference was induced by cortical electrostimulation during picture naming (using the DO-80) in 14 patients who were undergoing surgery for a glioma in the left IPL. The picture is oriented as in the operative position. ∅ = speech arrest; ▵ = anomia; ▴ = semantic paraphasia; □ = phonological paraphasia; ▪ = articulatory troubles; ⋄ = word telescoping; ♦ = noun gender error; × = increased latency; + = syntactic problems; Ψ = perseveration; ε = hesitation.

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    Summary of sites where contralateral sensorimotor responses were induced by cortical electrostimulation in 14 patients who were undergoing surgery for a glioma in the left IPL. The picture is oriented as in the operative position. Symbols mark involuntary movements: = hand/fingers; = face; = upper limb; = mouth; and dysesthesias: uncircled 1 = hand; = fingers; = upper limb; = face; = tongue; = lips.

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    Case 4. A: Intraoperative view of a subcortical functional mapping after tumor removal. The patient's head is turned to the right. The numbered tags mark functional sites in the white matter that were detected by direct cerebral stimulation under local anesthesia. In the superficial white matter under the cortical sites, the numbered tags represent the following: 44 = anomia (under T2p-AG); 49 = semantic paraphasia (under T1p); and 45 = articulatory troubles. In the deep white matter, the numbered tags represent the following: 50, 46, and 47 = phonemic paraphasias; 48 = upper-limb dysesthesias and slowness of movements. B: Postoperative T1-weighted sagittal MR imaging study showing enhancement at the site where phonemic paraphasias were induced (arrow), which led us to stop the resection, leaving a tumor residue in the depth of the surgical cavity.

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    Schematic drawings of the main fiber bundles encountered in the region of the left IPL. The picture is oriented as in the operative position. A: Horizontally oriented fiber bundles near the frontal and parietal opercula: the opercular segment of the SLF (SLF III) eliciting articulatory disturbances during stimulation (circle). B: In the deep white matter, the arcuate fascicle (arc) is seen, eliciting phonological paraphasia when stimulated (circle). Ag = angular gyrus; F1 = superior frontal gyrus; F2 = middle frontal gyrus; F3 = inferior frontal gyrus; SMg = supramarginal gyrus; T1 = superior temporal gyrus; T2 = middle temporal gyrus; T3 = inferior temporal gyrus.

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