Surgery for low-grade glioma infiltrating the central cerebral region: location as a predictive factor for neurological deficit, epileptological outcome, and quality of life

Clinical article

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Object

A main concern with regard to surgery for low-grade glioma (LGG, WHO Grade II) is maintenance of the patient's functional integrity. This concern is particularly relevant for gliomas in the central region, where damage can have grave repercussions. The authors evaluated postsurgical outcomes with regard to neurological deficits, seizures, and quality of life.

Methods

Outcomes were compared for 33 patients with central LGG (central cohort) and a control cohort of 31 patients with frontal LGG (frontal cohort), all of whom had had medically intractable seizures before undergoing surgery with mapping while awake. All surgeries were performed in the period from February 2007 through April 2010 at the same institution.

Results

For the central cohort, the median extent of resection was 92% (range 80%–97%), and for the frontal cohort, the median extent of resection was 93% (range 83%–98%; p = 1.0). Although the rate of mild neurological deficits was similar for both groups, seizure freedom (Engel Class I) was achieved for only 4 (12.1%) of 33 patients in the central cohort compared with 26 (83.9%) of 31 patients in the frontal cohort (p < 0.0001). The rate of return to work was lower for patients in the central cohort (4 [12.1%] of 33) than for the patients in the frontal cohort (28 [90.3%] of 31; p < 0.0001).

Conclusions

Resection of central LGG is feasible and safe when appropriate intraoperative mapping is used. However, seizure control for these patients remains poor, a finding that contrasts markedly with seizure control for patients in the frontal cohort and with that reported in the literature. For patients with central LGG, poor seizure control ultimately determines quality of life because most will not be able to return to work.

Abbreviations used in this paper:EOR = extent of resection; KPS = Karnofsky Performance Status; LGG = low-grade glioma.

Article Information

Address correspondence to: Hugues Duffau, M.D., Ph.D., Department of Neurosurgery, 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 14, 2013; DOI: 10.3171/2013.5.JNS122235.

© AANS, except where prohibited by US copyright law.

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    Images obtained in a female patient with LGG and a history of intractable seizures for 18 months before surgery, despite no abnormal findings on neurological examination. Preoperative tumor volume was 103 cm3. A: Preoperative axial FLAIR-weighted, sagittal enhanced T1-weighted, and coronal T2-weighted MR images showing a right central LGG involving both precentral and postcentral gyri. B: Intraoperative photographs before (left) and after (right) tumor removal. The letter tags on the preresection view correspond to the glioma boundaries identified using intraoperative ultrasonography. The number tags correspond to the eloquent cortical and subcortical structures, detected using direct electrical stimulation while the patient was awake. The resection was performed according to the following functional boundaries: 2, 3, 4 = primary motor cortex; 1, 5, 10, 15 = primary somatosensory cortex; 14, 15, 16, 23 = subcortical pyramidal and somatosensory pathways (deep limits of resection). C: Postoperative axial FLAIR-weighted, sagittal enhanced T1-weighted, and coronal T2-weighted MR images demonstrating subtotal resection. Postoperative tumor volume was 3 cm3 (EOR 97%). The patient completely recovered; clinical examination 3 months after surgery revealed no abnormalities. However, the patient continues to have intractable seizures, preventing her return to work despite the absence of neurological deficit.

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